^v  *   ,"  .-at. 


UNIVERSITY  OF  CALIFORNIA 
AT  LOS  ANGELES 


'•■..'    ,>r 


GIFT   OF   CAPT.   AND    MRS. 
PAUL   MCBRIDE  PERIGORD 


!  :.. 


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+    - 

<^.-^/.. 


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EAILWAY    INJURIES. 


AT 

Lus  ange:, "!•..<■■ 

LIBRARY 


EAILWAY    INJURIES: 


SPECIAL  REFERENCE  TO  THOSE  OF  THE  BACK  AND 
NERVOUS  SYSTEM, 

IN   THEIR 

MEDICO-LEGAL  AND  CLINICAL  ASPECTS. 


HERBERT    W.   PAGE,   M.A., 

M.C.  Cantab.,  F.R.C.S.  Eng. 

SURGEON   TO  ST.    MART'S  HOSPITAL,    AND  LECTURER  ON   SURGERY 

AT   ITS   MEDICAL  SCHOOL; 

CONSULTING    SURGEON    TO    THE    CUMBERLAND   INFIRMARY  ; 

EXAMINER   IN   SURGERY,    UNIVERSITY   OF   CAMBRIDGE. 


PHILADELPHIA : 
P.   BLAKISTON,    SON   &   COMPANY, 

1012  WALNUT  STREET. 
1891. 


144G()0 


.-0 
1 

t 


100 


1    ESTEEM    IT    A    HIGH    HOKOUU 

TO    BE    ALLOWED 

TO 

DEDICATE    THIS    BOOK 

TO    A    PHYSICIAN    AND    NEUROLOGIST    SO    ILLUSTRIOUS 


M.    CHARCOT. 


"  Hysteria  breaks  all  laws,  except  its  own  rules  of  eccentricity." 

— Weir  IMttcheli.. 


"The  figiire  of  Hj'steria  shrinks  in  proportion  as  the  various  forms 
of  organic  disease  acquire  greater  solidity  and  sharper  definition." 

— Buzzard. 


"  .Signs  are  facts  ;  thev  are  of  a  positive  character  :  they  may  be  at 
any  time  verified ;  they  never  mislead,  if  properly  used.  Symptoms 
are  quite  different :  they  are  generally  statements  rather  than  facts  ; 
they  are  statements  of  subjective  conditions  ;  they  are  generally  matter 
of  testimony,  accurate  and  true  or  inaccurate  yet  intended  to  be  true, 
or  inaccurate  and  intentionally  false  ;  they  are  seldom  capable  of  veri- 
fication. The  absence,  indeed,  of  symptoms  may  be  an  important 
symptom  or  indication." — Matthews  Duncax. 


INTEODUCTION. 


The  aim  of  this  book  is  to  give  an  account  of  the  injuries  sustained 
in  railway  and  similar  accidents  which  become  the  subject  of 
medico-legal  inquiry.     In  a  book  published  in  1883,  "Injuries  of 
the  Spine  and  Spinal  Cord  and  Nervous  Shock  "  (Churchill,  2nd 
ed.,  1885),  the  results  of  my  experience  up  to  that  time,  together 
gj       with  the  views  I  had  been  led  to  form  of  the  nature  of  railway 
^       injuries,  were  placed  on  record.      While  this  work  is  to  a  con- 
^       siderable  extent  founded  upon  the  book  of  1883,  and  draws  largely 
9,       from  it,  the  scheme  is  somewhat  different,  for  it  is  now  no  longer 
T        necessary  to  say  wherein  I  had  come  to  differ,  and  that  very  widely, 
P-        from  the  opinions  then  prevailing  as  to  the  nature  of  these  injuries. 
M       The  task  of  preparing  the  former  book  had  not  been  undertaken, 
S       it  is  right  to  say,  without  ample  personal  observation  of  the  cases 
^       and  injuries  described.    I  had  indeed  been  seeing  them  frequently 
^      during  a  period  of  nine  years,  and  from  the  beginning  I  had 
^       resolved  that  I  would  not  write  a  line  upon  the  subject  until 
after,  at  least,  five  years'  experience.      The  four  years  devoted  to 
the  preparation  of  that  book  afforded  time  for  an  inquiry  into 
the  after-histories  of  a  large  number  of  injured  persons,  and  a 
table  of  cases  formed  no  inconsiderable  part  of  it.      It  has  been 
impossible  again  to  undertake  the  extraordinary  and  systematic 
labour  which  that  inquiry  involved,  the  labour  of  travelling  thou- 
sands of  miles  and  the  inconvenience  of  frequent  absence  from 
London.      The  length  of  time  which  was  spent  over  the  prepara- 
tion of  the  former  work  has,  moreover,  been  fully  justified,  for 
although  I  have  more  to  say  in  the  present  work  than  I  said 
before,   yet   I  have   nothing  to    unsay  as  being  out   of   accord 
with  the  later  experience  of  eight  additional  years.      And  I  have 


vm  INTRODUCTION. 

the  further  satisfaction  of  knowing  that  the  views  which  I  then 
propounded  have  been  practically  accepted  by  all  who  are  familiar 
and  have  to  do  with  injuries  of  this  class,  both  in  this  country 
and  in  America,  as  well  as  in  France,  Germany,  and  elsewhere. 
It  is  unnecessary,  therefore,  again  to  travel  over  the  ground  which 
was  formerly  occupied  in  dealing  with  concussion  of  the  spinal 
cord  and  "  concussion  of  the  spine."  The  theory  which  attributed 
the  nervous  sjonptoms  after  railway  injury  to  meningo-myelitis  of 
the  brain  and  spinal  cord  no  longer  meets  with  general  accept- 
ance,"^ and  it  is  hardly  likely  to  regain  it  in  the  future,  unless  it 
has  the  support  of  more  pathological  and  clinical  facts  than  were 
originally  adduced  in  its  favour.  The  consequences  of  railway 
injury  are  happily  not  so  grave  as  that  theory  demanded,  but 
they  are  none  the  less  deserving  of  attention  because  of  the 
serious,  albeit  usually  transient,  effects  which  are  wrought  upon 
the  nervous  system  by  this  form  of  accident. 

Eenewed  attempts  have  been  made  in  recent  years  to  unravel 
and  explain  the  complex  nature  of  collision  injuries ;  and  by 
many  writers  in  this  country  and  abroad,  by  Thorburn,  Dresch- 
feld,  Eoss,  and  Collier  here ;  by  Weir  Mitchell,  Dana,  Hodges, 
Putnam,  and  others  in  America ;  by  Charcot  and  many  of  his 
disciples,  by  Guinon  and  Berthez,  Moricoiu-t,  Terrier,  and  Yibert 
in  France ;  by  Oppenheim,  Striimpell,  Bernhardt,  and  "Westphal 
in  Germany,  and  by  a  host  of  others,  fresh  light  has  been 
shed  upon  the  traumatic  psycho-neuroses  and  on  the  hysterical 
and  neurasthenical  conditions  which  are  prone  to  ensue  from 
the  profound  mental  disturbance,  and  the  shock  to  the  whole 
nervous  system,  which  a  railway  accident  causes.  This  practi- 
cally was  the  view  which  I  sought  to  uphold,  that  most  of  the 
strange  nervous  symptoms  so  commonly  seen  after  railway 
accidents  were  not  due  to  physical  injury  sustained  by  the 
spinal  cord,  but  were  the  more  or  less  immediate  concomi- 
tants of  the  profound  mental  emotion  aroused  by  the  unques- 
tionably special  features  and  incidents  of  every  collision.  And 
I  endeavoured  to  show  how  the  accompaniment  of  some  form 
of  injury  to  extra-spinal,  muscular,  and  ligamentous  structures 

^  "  Est  defiuitivement  abaiulounee"  is  the  expression  of  a  French  writer, 
Dr.  Dutil. 


INTRODUCTION.  ix 

was  at  the  root  of  the  entirely  erroneous  notion  that  the  ner- 
vous symptoms  were  due  to  lesion  in  that  part  of  the  central 
nervous  system  which  has  its  seat  in  the  spinal  column.  The 
further  experience  gained  since  I  last  wrote  has  confirmed  the 
opinions  which  I  then  expressed  ;  and  the  extensive  opportunities 
which  I  enjoyed  of  studying  this  class  of  injuries  during  my 
seventeen  years'  tenure  of  the  office  of  Surgeon  to  the  London 
and  ISTorth-Western  Eailway  Company,  warrant  me  now  in  laying 
before  the  profession  in  a  more  comprehensive  manner  what  I 
have  to  say  on  the  subject  of  Eailway  Injuries. 

The  book  makes  no  pretension  to  be  a  text-book  of  nervous 
diseases.  It  is  simply  one  chapter  in  their  history ;  and  if  for 
convenience'  sake  it  is  itself  divided  into  chapters,  it  is  as  one 
chapter  on  the  subject  of  which  it  treats  that  it  must  be  read. 
The  various  parts  of  it  are  meant  to  hold  together,  and  if  the 
statements  made  are  not  every  one  of  them  supported  by  the 
published  record  of  individual  cases,  none  the  less  are  they 
founded  on  actual  experience  and  observation.  I  have  throughout 
endeavoured  fairly  and  evenly  to  hold  the  balance,  bearing  in 
mind  that  no  work  upon  such  a  subject  can  be,  as  I  am  desirous 
this  should  be,  of  use  to  others,  unless  it  is  conceived  in  a 
judicial  spirit,  and  is  free  from  partiality  and  bias. 

In  conclusion,  I  have  to  express  my  thanks  to  my  friend  Mr. 
Thorburn  for  many  valuable  suggestions. 


HERBERT  W.  PAGE. 


146  Harley  Street,  W., 
December  1890. 


CONTENTS. 


CHAP. 

I.  INJURIES  OF  THE  BACK     .     .     .     .     . 
H.  GENERAL  NERVOUS  SHOCK   .     .     •     .     . 

III.  GENERAL  NERVOUS  SHOCK  {continued)  . 

IV.  THE    FRIGHT   NEUROSES TRAUMATIC    HYSTERIA 

V.  THE  FRIGHT  NEUROSES  {continued) 

VI.    ON    TREATMENT     ....... 

VII.    MALINGERING         ....... 

VlII.    THE    MEDICO-LEGAL    ASPECT    OF    RAILWAY    INJURIES 
BIBLIOGRAPHY      ....... 

INDEX     ........ 


25 

49 
61 

75 
98 

105 
127 

138 
142 


RAILWAY    INJURIES. 


CHAPTER  I, 

INJURIES   OF   THE   BACK. 

SuMMAEt. —  I.  Their  frequency.— 2.  Mode  of  occurrence. — 3.  Association  with  "ner- 
vous shock."— 4,  Stiffness,  pain,  tenderness. — 5.  The  small  spinal  joints. — 
6,  Pseudo-paralysis. — 7.  Real  difficulty  in  micturition  and  constipation. — 8.  Fear 
of  moving. — 9.  Character  and  duration  of  spinal  pain. — 10,  Hypersesthesia  of 
the  back. — 11.  Peripheral  sensations  after  spinal  injury. — 12.  Need  for  absolute 
rest. —  13.  Concomitant  nerve  lesions.  —  14.  Myelitis  and  meningitis.  —  15 
Syphilis  and  pachymeningitis. — 16.  Risk  of  future  spinal  cord  degeneration. — 
17.  Associated  neurasthenia  and  the  influence  of  compensation  on  recovery. 

1.  The  object  of  this  chapter  is  to  give  an  account  of  the  spinal  Their  fre- 
injuries  vvhicli  are  so  frequent  in  railway  collisions.  It  is,  of  course,  ^^ 
true  that  injuries  o£  all  kinds  and  degrees  are  caused  by  railway 
accidents,  but  they  differ  in  no  respect  from  those  which  are  seen 
after  any  and  every  form  of  violence.  Nor  indeed  do  injuries  of 
the  back  received  in  railway  accidents  differ  from  injuries  of  the 
back  received  in  many  other  ways,  but  their  frequency,  and  above 
all  the  character  which  they  impress  on  the  features  of  many 
other  forms  of  railway  injury,  especially  on  those  which  will  be 
dealt  with  in  the  succeeding  chapters,  demand  for  them  a  place 
by  themselves,  and  a  separate  chapter  for  their  consideration. 
Their  frequency  is  a  matter  of  no  question.  It  has  been  attested 
by  Riegler,^  by  every  one,  in  fact,  who  has  ever  written  on  the 
subject  of  railway  injuries,  while  amongst  my  own  cases  more  than 
60  per  cent,  of  the  injured  persons  made  some  complaint  at  some 
time  or  other  of  having  been  hurt  in  the  back.      The  influence  of 

^  Ueber  die  Foli/cn  der  Terletzungcn  auf  Eiscnhahnen,  insbcsondere  der  Terletz- 
nngen  des  Riichcnmarks,  Berlin,  1879.  Riegler  gives  statistics  which  show  that,  since 
the  passing  of  a  law  in  Germany  for  the  compensation  of  persons  injured  on  railways, 
the  number  of  injuries  or  complaints  of  injuries  had  enormously  increased,  and  that, 
moveover,  of  thirty-six  complaints  after  injury  no  fewer  than  twenty-eight  were  of 
the  back. 

A 


2  RAILWAY    INJUIITES. 

such  injuries  upon  the  more  purely  nervous  effects  of  railway 
accidents  it  will  be  one  purpose  of  this  book  to  teach,  and  those 
who  do  more  than  merely  skim  its  pages  will  find  how  true  it  is, 
that  the  complexion  of  the  other  injuries  to  be  described  may  be  at 
times  affected,  or  even  changed,  by  them. 

I  will  speak  in  the  first  place  of  the  more  common  injuries  of 
the  back  received  in  collisions  on  railways  or  in  other  similar  acci- 
dents, and  will  refer  afterwards  to  those  conditions  or  symptoms, 
which  indicate  that  there  may  have  been  injury  to  one  or  other  of 
the  nerve  elements  of  the  spinal  column.  And  it  may  be  well  to 
premise  that  in  none  of  the  cases  quoted  was  there  any  reason 
to  suspect  the  perfect  bona  fides  of  the  injured  persons.  The 
following  is  a  very  frequent  occurrence.  *  A  man  has  been  in  a 
collision ;  he  was  perfectly  conscious  at  the  time  that  he  met 
with  no  blow — knows,  in  fact,  exactly  what  occurred  to  him 
when  the  accident  happened,  and  yet  he  finds  that  within  a  few 
hours,  occasionally  much  sooner,  he  is  seized  with  pain  in  his 
back.  What  has  happened  to  him  ?  Let  us  look  at  a  case  where 
the  symptoms  were  simple  and  unobscured  by  other  injury. 

Case  i. — Simple  lumbar  sprain, — Traumatic  lumbago. — ]\I.  A., 
a  strong  and  active  man,  was  riding  in  a  first-class  carriage, 
when  a  slight  collision  took  place.  He  was,  at  the  moment, 
leaning  forwards  reading,  and  was  not  even  moved  from  his 
seat.  He  felt  a  little  upset  and  shaken,  and  had  some  brandy 
in  consequence,  but  he  was  able  in  a  few  minutes  to  set  off  and 
walk  to  his  business.  The  next  day  he  felt  some  pain  in  the 
lumbo-sacral  region,  which  on  the  following  day  became  acute, 
especially  on  movement,  and  on  the  third  and  fourth  days  after 
confined  him  to  the  house.  He  was  ordered  a  belladonna  plaster, 
and  in  a  week  he  began  to  improve,  though  having  occasionally 
sharp  pain.  There  was  no  local  tenderness,  and  it  is  evident  from 
the  history  that  the  injury  in  this  case  was  a  simple  sprain  of  the 
muscles  and  ligaments  about  the  lumbo-sacral  region.  It  was,  in 
fact,  a  "  traumatic  lumbagfo." 


Mode  of  2.   In  a  slight  collision  like  this  it  is  very  common  to  hear  that 

the  po,ssenger  was  thrown  backwards  and  forwards  in  the  carriage, 
and  although  this  man  had  hardly  been  moved,  the  sudden  arrest 
of  the  train  is  frequently  the  means  of  jerking  the  traveller  from 
his  seat,  and  perhaps  landing  him  upon  the  floor.  Now  it  is 
that  the  phj'Sical  structure   of  the   spinal   column  exposes  it   to 


occur 
reu.e. 


INJURIES    OF    THE    BACK.  3 

tliis  form  of  injury.  Endowed  with  extreme  mobility  in  every 
direction,  forwards,  backwards,  in  rotation,  and  from  side  to 
side,  as  provided  by  its  many  articulations  and  by  its  thousand 
muscular  and  ligamentous  attachments,  it  nevertheless  has  to 
guard  the  spinal  cord  within  its  central  canal.  To  do  this  well, 
both  conscious  and  unconscious  effort  is  made  at  the  moment 
of  the  collision  to  hold  the  column  rigid,  and  as  a  result  of  the 
violence  aud  of  the  sudden  resistance  induced  by  "  setting "  of 
the  muscles  and  ligaments,  the  ligaments  and  muscular  attach- 
ments are  strained,  overstretched,  and,  it  may  be,  even  ruptured 
in  the  dorso-lnmbar  or  lumbo-sacral  regions  of  tbe  column.  The 
injury  is  precisely  the  same  as  that  which  is  met  with  every  day, 
where  a  man  complains  that  while  lifting  a  heavy  weight  he 
suddenly  felt  a  severe  and  acute  pain,  which  almost  prevented 
him  from  moving,  in  the  lower  part  of  his  back.  You  examine 
him  and  can  find  no  external  sign  of  injury,  but  he  hesitates  to 
stoop  when  you  ask  him,  he  holds  his  back  unnaturally  stiff,  he 
finds  it  difficult  or  impossible  to  rise  from  his  seat,  and  very 
likely  there  is  some  local  tenderness  in  the  muscular  mass  on 
either  side  of  the  lumbar  vertebrae.  We  may  meet  with  the 
same  injury  in  very  different  degrees  of  severity,  and  the  pain 
may  be  felt  at  an  altogether  different  part  of  the  spinal  column. 

Case  2. — Cervico-dorsal  sprain. — A  man  aged  forty-two  was  in  a 
train  which  ran  (without  time  for  warning)  at  fifty  miles  an  hour 
into  a  coal  train  standing  on  the  line.  He  was  thrown  suddenly 
forwards,  and  instantly  felt  acute  pain  in  the  cervico-dorsal  region. 
The  pain  was  never  again  acute,  but  a  weary  aching  was  felt  at  the 
part  for  several  weeks,  both  over  and  on  each  side  of  the  spine. 
There  were  no  other  indications  of  injury,  and  the  nausea  and 
feeling  of  faintness  experienced  at  the  moment  of  the  accident 
soon  passed  away.  Obviously  the  injury  in  this  case  was  of  pre- 
cisely the  same  nature  as  the  traumatic  lumbago  already  named. 
The  spinal  injury  may,  however,  be  even  more  widespread. 

Case  3. — Sprain  of  the  whole  vertebral  column. — A  rather 
smart  collision  caught  a  man,  aged  fifty-eight,  sitting  upright  in 
the  carriage  with  his  head  slightly  turned  to  one  side.  He  was 
thrown  back,  and  his  head  was  knocked  against  the  partition,  the 
brim  of  his  hat  fortunately  saving  him  from  a  severer  blow.  He 
felt  shaken  and  sick,  but  did  not  vomit.  Within  a  couple  of 
hours  of  the  accident  he  was  seized  with  pain,  and  tenderness  was 
felt  in  the  lower  part  of  the  back,  especially  over  the  two  lower 


4  RAILWAY    IXJUPtlES. 

dorsal  and  two  upper  lumbar  vertebrge.  He  was  taken  home  and 
put  to  bed,  where  he  lay  for  a  month  suffering  at  first  from  such 
severe  pain  throughout  the  whole  spine — cervical,  dorsal,  lumbar 
and  sacral,  regions — that  he  was  barely  able  to  move.  There 
was  never  any  acceleration  of  pulse,  elevation  of  temperature,  or 
peripheral  pain.  At  the  end  of  the  month  he  began  to  improve, 
and  was  able  to  move  his  arms  and  his  head  without  pain,  and 
occasionally  to  sit  up  in  bed.  In  a  couple  of  months  he  was  able 
to  get  up,  and  in  three  months  to  move  about  so  well  as  to  do 
a  little  business.  He  gradually  recovered,  and  five  years  after 
the  accident  was  reported  to  be  in  good  health,  although  he  still 
felt  an  "  uncertainty"  when  travelling,  and  unless  he  carefully 
supported  himself  was  liable  to  have  a  return  of  pain  in  the  lower 
part  of  the  back. 


Association  3.  These  cases  afford  good  examples  of  the  same  kind  of  injury, 
"nervous  tliough  affecting  diflFerent  parts  of  the  spine.  It  is  unusual,  how- 
shock."  ever,  to  meet  with  cases  such  as  these  where  there  is  no  other 
complication.  "Nervous  shock"  in  its  varied  manifestations  is  so 
common  after  railway  collisions,  and  plays  so  prominent  a  part 
in  all  cases  which  become  the  subject  of  medico-legal  inquiry, 
whether  they  be  real  or  feigned,^  that  we  are  almost  sure  to 
meet  with  the  symptoms  of  it  in  association  with  pains  in  the 
back,  and  with  points  of  tenderness  along  the  vertebral  spinous 
processes.  It  is  this  frequent  combination  of  the  symptoms  of 
general  nervous  prostration,  neurasthenia,  or  shock  with  pains 
in  the  back,  such  as  these  cases  presented,  which  no  doubt  laid 
the  foundation  of  the  erroneous  views  which  were  at  one  time 
prevalent  as  to  the  nature  of  the  common  injuries  of  the  back 
received  in  railway  collisions. 

A  man  has  a  general  nervous  shock,  and  at  the  same  time  he 
is  alarmed  himself,  and  gives  continued  alarm  to  others  by  the 
pain  and  tenderness,  often  very  sevei-e,  which  he  suffers  at  some 
part  of  the  spinal  column,  or  of  the  structures  lying  contiguous  to 
it.  In  the  first  two  cases  recorded  there  can  be  no  question  that 
simple  muscular  or  ligamentous  strain  was  the  sole  cause  of  the 

■*  In  the  Times,  of  Satnrda}',  February  19,  18S1,  a  case  was  recorded  of  an  action 
against  a  railway  company  for  injuries  received  by  a  man  in  accidentally  putting  his 
leg  through  a  hole  whereby  lie  was  thrown  down  and  hurt  his  leg.  The  Judge  com- 
mented strongly  on  the  fact  that  the  symptoms  complained  of  bore  a  strange  resem- 
blance to  those  heard  of  so  frequently  after  railway  collisions.  The  symptoms,  I 
think,  in  such  cases  ought  properly  to  be  termed  "  litigation  symptoms,"  as  I  shall 
subsequently  show. 


INJURIES    OF   THE   BACK.  5 

pain:  and  the  entire  absence  of  any  indication  of  other  injury 
shows  that  the  cause  of  the  pain,  which  extended  throughout  the 
whole  spinal  column,  and  made  every  movement  of  trunk  and 
limb  almost  intolerable,  was  exactly  the  same  in  the  third  and 
more  serious  case.  Cases  like  the  last  are  rarely  met  with  in 
ordinary  practice,  but  railway  collisions  provide  the  conditions 
which  determine  the  possibility  of  such  extensive  strain  of  the 
vei-tebral  column.  Now  one  part,  now  another,  is  sprained  in 
the  jerks  and  jolts  which  accompany  most  collision  accidents,  and 
the  pain,  more  commonly  situated  in  the  lumbar  region  alone, 
may  thereupon  affect  other  parts  of  the  column.  And  very 
variable  may  be  this  pain  both  in  range  of  distribution  and  in 
character ;  and  variable  also  the  time  when  it  may  begin. 

Case  4. — Lumhar  sprain — Veri/  acute  pain. — A  young  man 
who  was  in  a  bad  collision  began  three  da3-s  afterwards  to  feel 
pain  and  stiffness  across  the  loins,  so  that  he  moved  with  diffi- 
culty, and  felt  easiest  when  flat  upon  his  back.  The  pain  in 
his  back  gradually  increased,  and,  to  use  his  own  woi'ds,  he 
thought  all  was  over  with  him,  and  that  he  was  going  to  be 
paralysed,  for  when  he  tried  to  stand  up  a  sharp  pain  seized 
him  in  the  back  like  a  knife  cutting  into  him,  and  shot  down- 
wards and  upwards  from  the  loins  like  an  electric  shock,  so 
that  he  dropped  upon  the  floor.  This  state  of  things  lasted  for 
about  three  weeks,  during  which  he  lay  almost  helpless,  and  had 
the  greatest  difficulty  in  defecation  and  micturition.  There  was 
at  the  same  time  considerable  local  tenderness,  but  never  any 
outward  sign  of  injury.  This  description  is  almost  characteristic 
of  an  attack  of  acute  lumbago. 


4.  Stiffness,  however,  and  local  pain  are  not  the  only  indications  Stiffness, 
of  spinal  sprain.  There  is  very  often  some  degree  of  local  tender-  tend'emes 
ness  as  well,  felt  on  pressure  over  one  or  more  spinous  processes, 
or  occupying  a  wider  area  on  each  side  of  the  spine,  and  it  is 
important  to  inquire  whether  this  is  evidence  of  some  graver 
injury  than  I  have  said  is  ordinarily  signified  by  the  local 
pain.  My  own  experience  lends  no  support  to  this  supposition. 
Local  tenderness  is  often  found  in  cases  of  simple  sprain  of  the 
back  from  lifting  heavy  weights,  and  it  would  be  very  strange 
if  the  same  symptom  were  not  found  in  those  cases,  where  the 
spinal  sprain  has  been  caused  by  the  severe  wrenching  and 
straining   suffered    in   a    railway    collision.      In   the   worse   cases 


O  RAILWAY    INJURIES. 

fthe  same  conditions  are  in  all  probability  produced  as  are  to  be 
found  around  an  ankle  or  other  joint  which  has  been  sprained, 
'  but  you  cannot  see  the  swelling  about  the  small  joints  of  the 
vertebral  column  and  about  the  muscular  and  ligamentous  attach- 
ments, simply  because  the  structures  sprained  are  more  deeply 
situated,  and  are  much  smaller  in  size.  A  deep-seated  discolora- 
tion, however,  may  be  sometimes  seen,  even  where  there  has  been 
no  blow.  Tenderness  is  thus  a  more  or  less  inevitable  conse- 
quence of  the  injury,  but  is  it  by  itself  a  more  dangerous  symptom 
than  the  pain  on  movement  ?  Let  us  ask  if  tenderness  of  the 
back  is  a  prominent  symptom  in  cases  of  spinal  cord  disease 
which  we  see  in  our  hospital  wards  ?  Is  it  not  rather  conspicu- 
ously absent,  and  is  not  a  diagnosis  made  by  a  totally  different 
train  of  symptoms  ?  Any  one  who  has  ever  looked  at  a  vertical 
section  through  the  centre  of  the  spinal  column,  and  has  noted 
how  far  the  spinal  cord  is  from  the  surface,  how  the  spinous  pro- 
cesses overlap  each  other,  and  how  thick  is  the  mass  of  muscles 
on  either  side,  must  have  felt  convinced  that  all  ordinary  pressure 
on  the  column  can  have  little  or  no  effect  upon  the  structures 
within.  Tenderness  by  itself  is  therefore  not  to  be  regarded 
as  an  indication  of  grave  injury  to  the  contents  of  the  spinal 
column ;  it  is  a  symptom,  which,  if  of  any  value  at  all,  ought 
rather  to  reassure,  as  pointing  to  the  kind  of  injury  which  we 
are  here  considerinsr. 


The  small 

spinal 

joints. 


5.  But  although  local  tenderness  may  be  of  small  value  as  evi- 
dence of  intra-spinal  lesion,  its  long  continuance  at  one  spot  is  very 
decidedly  suggestive  of  some  inflammatory  affection  of  one  of  the 
small  spinal  joints.  "It  may  be  deemed  singular,"  Mr.  Shaw 
writes  in  Holmes'  "  System,"  ^  "  that  numerous  as  are  the  small 
joints  formed  by  the  opposing  surfaces  of  the  oblique  processes, 
in  the  posterior  segment,  disease  is  scarcely  ever  witnessed  in 
them."  Yet  we  know  that  these  joints  may  be  very  seriously 
affected  in  rheumatoid  arthritis,  and  that  they  do  not  escape 
suppuration  in  pya3mia.  There  is  no  inherent  reason  why  one 
or  more  of  them  should  not  occasionally  be  affected  by  a  simple 
synovitis,  such  as  is  seen  in  other  and  larger  joints  as  the  result 
of  injury.  Traumatic  synovitis  of  a  spinal  joint  is  doubtless 
extremely  rare,  but  it  may  be  occasionally  the  cause  of  otherwise 
inexplicable  tenderness  and  pain. 

^  Holmes'  Systim,  vol.  iv.,  2nd  ed.,  p.  103. 


INJURIES    OF    THE    BACK.  7 

6.  The  three  most  prominent  and  distinctive  signs  of  simple  Pseudo- 
sprain  of  the  back  commonly  met  with  are  stiffness,  tenderness,  and  ^^''^  ^^^^' 
pain,  and  we  have  seen  that  these  may  be  present  at  any  part  of  the 
spinal  column,  or  may  even  involve  the  whole  of  it.  This  widely 
distributed  "  lumbago  " — if  the  term  may  be  allowed  to  indicate 
the  aching  and  the  pain  on  movement  throughout  every  part  of 
the  spinal  column — may  of  itself  give  rise  to  a  form  of  pseudo- 
paralysis, which,  if  unrecognised,  may  cause  unwarranted  alarm. 
The  pain  in  all  movements  may  be  so  great,  whether  the  move- 
ments be  of  the  limbs,  of  the  body,  or  of  the  head,  that  the  patient 
is  really  afraid  to  move  at  all.  This  well-grounded  fear  of  moving 
may  soon  assume  the  importance  of  an  absolute  inability  to  move, 
especially  when  the  sprain  has  chiefly  affected  the  lumbar  and 
lumbo-sacral  regions.  Ask  any  man  who  has  had  a  severe 
lumbago,  whether  from  a  sprain,  from  rheumatism,  or  from  cold, 
if  he  has  not  at  the  same  time  felt  a  strange  sense  of  difficulty 
in  moving  his  legs.  Brisk  walking  becomes  impossible  ;  the 
effort  needed  to  put  one  leg  before  the  other  must  be  unnaturally 
great ;  fatigue  comes  early,  and  the  patient  complains  to  you 
that  his  legs  feel  weak,  and  as  if  he  could  hardly  move  them. 
The  injury  may  frequently  be  diagnosed  by  the  peculiarity  of 
the  erait  alone. 


7.  Micturition  may  at  the  same  time  be  interfered  with,  from  Real  diffi- 
lack  of  the  natural  support  and  help  which  the  lumbar  muscles  micturition 
provide  when  this  act  is  being  performed.  The  patient,  perhaps,  gtip^yon. 
cannot  completely  empty  his  bladder,  and  there  is  a  certain 
amount  of  dribbling  at  the  close  of  the  act.  It  thus  appears 
to  himself  that  his  "water  runs  from  him,"  and  if,  as  a  con- 
sequence of  slight  retention,  there  be  added  some  irritability 
of  bladder,  symptoms  of  somewhat  ominous  import  seem  to  be 
developed.  Many  men  find  it  practically  impossible  to  empty 
their  bladders  when  they  are  laid  upon  their  backs,  and  "  residual 
urine,"  recognised  as  perhaps  the  most  frequent  cause  of  cystitis, 
is  very  prone  indeed  to  occur  as  the  indirect  result  of  any  injury 
which  dooms  a  man  to  bed.  And  this  may  arise  quite  indepen- 
dently of  any  retention  due  to  shock,  to  which  reference  will  be 
found  at  p.  45.  It  is  obvious,  therefore,  that  sprains  of  the 
lower  back  provide  the  very  combination  of  conditions  likely  to 
lead  to  this  result,  and  every  now  and  then  we  find  that  trouble 
with  the  bladder  may  rise  into  considerable  pi-ominence.  Especially 
is  this  likely  to  happen  when  the  nervous  system  has  been  much 


movinc 


8  IIAILWAY    INJURIES. 

upset  by  the  shock  of  the  accident,  and  you  may  find  a  condition 
of  "  nervous  bladder,"  in  which  the  patient  has  a  frequent  desire 
to  pass  water,  with  inability  at  the  same  time  to  perform  the  act 
perfectly,  and  consequent  slight  diibbling  at  its  close.  Constipa- 
tion also  arises  from  the  same  muscular  incapacity,  and  becomes 
an  almost  invariable  feature  in  the  case.  Thus  it  is  nothing  more 
nor  less  than  natural  for  the  friends  to  say  that  the  patient  is 
"paralysed,"  and  paralysed  from  severe  injury  to  the  spine.  If 
you  do  not  avoid  these  fallacies,  and  do  not  correctly  interpret 
this  state  of  things,  you  will  add  greatly  to  the  dread,  which 
after  railway  collisions  is  strangely  real,  that  "  paralysis "  is 
going  to  supervene. 


Fear  of  8.   This  Very  natural  fear  of  paralysis  is  still  further  increased 

by  the  abnormal  sensations  incidental  to  the  muscular  and  liga- 
mentous incapacity.  There  is  a  strange  feeling  of  weakness  in 
the  legs,  and  the  patient  complains  to  you  that  he  cannot  walk, 
or  that  his  legs  give  way  when  he  makes  the  attempt  to  do  so. 
Repeated  observation,  however,  leaves  no  doubt  in  my  mind 
that  these  results  are  more  dependent  on  the  fear  of  moving 
than  on  any  real  inability  to  move  because  of  nerve  lesion ;  and 
the  personal  knowledge  of  many  hundreds  of  cases,  together 
with  the  absence  of  any  record  of  such  a  consequence  in  medical 
literature,  enables  me  to  allege  that  there  is  no  more  cause  to 
anticipate  real  paralysis  after  a  sprain  of  the  back  received  in 
a  railway  collision,  than  there  is  after  the  thousand  and  one 
different  kinds  of  injury  which  fall  under  the  notice  of  the 
surgeon. 
j  In  the  absence  of  other  signs  of  injury  for  which,  of  course, 
Y  full  search  will  be  made,  do  not  therefore  let  undue  weight  be 
1  given  to  this  pain  and  tenderness  at  one  or  more  points  of  the 
J  spinal  column,  or  to  the  stiffness  and  pseudo-palsy  which  ac- 
company them.  In  cases  of  real  damage  to  the  spinal  cord  or 
its  membranes,  both  pain  and  tenderness  may  help  to  localise 
the  point  at  which  mischief  is  going  on,  bat  they  do  not 
indicate  the  mischief  itself,   nor  are  they  in  any  sense  patho- 

^  This  fear  of  moving  was  strangely  shown  by  a  man  who  had  receis'ed  such 
injuries  as  have  been  described,  who  was  confined  to  bed  in  consequence,  and  who 
needed  three  persons  to  help  him  out  of  bed  every  time  he  wanted  to  pass  water  in 
the  daytime.  To  himself  it  appeared  wholly  unaccountable  and  extraordinary  that 
whenever  he  woke  in  the  night  he  could  jump  naturally  out  of  bed  without  any  help 
for  the  same  purpose.     It  need  hardly  be  said  that  the  case  was  perfectly  genuine. 


INJURIES    OF    THE    BACK.  9 

gnomonic  symptoms  of  spinal  cord  disease.  In  no  wise  would 
I  undervalue  the  real  importance  of  these  vertebral  sprains. 
They  may  be  exceedingly  distressing  to  the  patient ;  the  pains 
may  last  for  a  very  long  time ;  there  may  even  be  occasional 
reminders  of  pain  for  months  or  years  under  suitable  conditions ; 
but  it  is  right  that  we  should  attach  no  more  import  to  them 
than  they  deserve,  and  their  existence  should  not  entail  a  needless 
dread  of  serious  injury  to  the  structures  within  the  spinal  canal. 


9.  The  long  continuance  of  pain  in  the  back  is  very  naturally  Character 
the  cause  of  alarm  to  the  patient,  and  of  doubts  as  to  his  ulti-  tkin  of '^''' 
mate  recovery;  but  if  the  pain  be  rightly  estimated,  and  its  real  spmaipam. 
value  as  a  symptom  of  spinal  disease  be  recognised,  there  will 
be  less  reason  for  these  fears.  Look  at  it  in  connection  with 
maladies  other  than  simple  sprain.  In  spinal  caries,  for  example, 
we  know  that  local  pain  at  the  site  of  disease  is  not  one  of 
the  most  pronounced  symptoms,  and  that  it  is  of  much  less 
value  in  diagnosis  than  pains  at  the  periphery,  instinctive  dread 
of  leaving  the  recumbent  posture,  or  an  absence  of  natural 
flexibility  in  the  spinal  column  when  the  patient  moves.  The 
pain,  indeed,  is  indicative  of  nothing  more  serious  than  muscular 
or  ligamentous  strain.  In  character,  moreover,  it  may  be  said 
to  be  almost  tyj^ical  of  this  form  of  injury.  Aching,  weary,  and 
more  or  less  constant  both  over  and  near  the  spine,  and  in 
the  muscular  masses  on  either  side  of  it,  it  is  liable  to  be 
rendered  acute  by  movement,  so  that  the  patient  dreads  to  move 
at  all ;  or  if  he  be  able  to  go  about,  it  is  likely  to  seize  him 
suddenly  and  sharply,  to  make  him  cry  out  for  the  moment,  and 
to  be  followed  by  renewed  aching  of  the  back.  The  spinal  pains 
are,  indeed,  very  like  the  pains  which  may  affect  any  contused 
or  sprained  joint,  and  there  is  precisely  the  same  indication  for 
treatment.  Exercise — and  not  fixation  of  the  whole  back  in 
poroplastic  jackets — is  essentially  the  best  thing  for  relieving 
them,  after  adequate  rest  has  been  given  to  recover  from  the 
immediate  effects  of  the  shock,  and  to  avoid  what  risk  there  may 
be  from  too  early  movement  of  the  bruised  and  strained  parts. 
True,  the  effort  necessary  to  move  for  the  first  time  may  have  to 
be  very  great,  and  the  pain  on  first  getting  out  of  bed  or  attempt- 
ing to  walk  may  be  so  acute  as  to  drive  the  patient  back  to  bed 
again,  yet  if  this  initial  pain  will  be  endured,  and  a  little  per- 
severance and  determination  be  exerted,  it  is  pretty  certain  that 
the    pain  will  daily  be  lessened,   and  that   greater   freedom    of 


lO  r.ATLWAY    INJURIES. 

movement  will  be  gained  at  the  same  time.  In  a  sprained  joint 
we  know  that  stiffness  and  pain  go  frequently  ^:)ar'i  passu  together, 
and  the  same  associated  phenomena  in  these  injuries  of  the  back 
form  an  additional  aid  to  the  diagnosis  that  the  spinal  pains  are 
not  of  more  serious  import,  than  those  due  to  muscular  and  liga- 
mentous strain  elsewhere.  They  share  this  feature  likewise  in 
common  with  them,  that  they  have  a  tendency  to  last  obstinately 
for  a  long  time  ;  to  recur  after  intervals  of  comparative  or  entire 
ease ;  to  be  induced  by  changes  in  the  weather,  or  by  any  extra 
exertion  ;  and  so,  by  their  very  nature,  they  unduly  alarm  the 
patient,  and  encourage  him  in  the  belief  that  his  injuries  have 
been  greater  than  they  really  are,  and  that  the  prospect  of  his 
recoveiy,  without  permanent  damage  or  disablement,  is  very  remote 
indeed.  It  behoves  us  not  to  share  in  his  alarm,  but  rather  to 
use  every  influence  to  induce  the  patient  to  take  those  steps 
which  alone  can  ensure  his  recovery — to  leave  his  bed,  to  have 
change  of  air,  if  need  be,  to  improve  his  general  health,  and  to 
allow  of  greater  opportunities  of  movement  than  were  he  to 
stay  at  home.  Be  careful,  however,  before  all  things,  not  to 
overlook  any  symptom  which  is  a  real  indication  of  injury  of 
the  spinal  membranes  or  of  disease  of  the  spinal  cord. 


Hyperaes-  10.  Not  for  this  reason  only  is  it  desirable  to  make  a  correct 
thrbacV:.  diagnosis  as  soon  as  possible,  but  also  because  there  are  few  things 
worse  for  a  patient,  whether  man  or  woman,  than  for  the  back  to 
be  constantly  examined,  and  for  pain  and  tenderness  to  be  elicited 
over  and  over  again  at  the  injured  parts.  Eepeated  examination 
is  the  very  way  to  develop  a  state  of  undue  nervousness,  and  to 
bring  about  a  hyperaesthesia  of  the  surface  which  is  often  most  dis- 
tressing. Just  as  hyperesthesia  over  a  wide  region  of  the  skin  of 
the  hip  may  be  seen  in  cases  of  so-called  hysterical  coxalgia,  so  a 
widely  diffused  sensitiveness  of  the  skin  of  the  back  may  arise  in 
many  cases  of  simple  sprain  unassociated  with  other  disease  of 
the  spinal  column.  Its  onset  and  development  may  occasionally 
be  observed,  and  its  real  origin  be  thus  made  manifest. 

Case  5. — Sprain  of  the  dorsal  and  lumhar  verteorce — Great  sur- 
face hypercesthesia. — A  young  man  was  slightly  shaken  in  a  collision 
of  no  great  severity,  and  in  a  few  days  had  pains  about  the  verte- 
bral column  such  as  have  been  described.  He  gradually  recovered 
from  the  effects  of  the  shake,  but  the  aching  in  the  back  con- 
tinued,  and  the   spine  was  therefore  more  especially  examined, 


INJURIES    OF    THE    BACK.  I  I 

not  much  attention  having  been  paid  to  it  hitherto.  The 
examination  revealed  a  point  of  tenderness  on  pressure  over  one 
of  the  dorsal  vertebra),  at  the  point  in  fact  where  the  sprain  had 
probably  been  most  severe.  Within  a  day  or  two  his  back 
became  so  sensitive  that  he  complained  of,  and  shrank  from,  the 
very  lightest  touch  of  the  finger  on  almost  every  part  of  it,  whether 
over  the  spinal  column  or  over  the  muscles  at  the  side.  He  was 
so  sensitive  to  touch  that  he  endeavoured  to  avoid  being  touched 
at  all,  seemed  even  afraid  to  have  his  back  looked  at,  and  moved 
himself  away  with  so  much  contortion,  as  in  itself  to  afford 
evidence  of  the  absence  of  any  serious  mischief  about  the  ver- 
tebral column  or  its  contents.  The  hypergesthesia  was  doubtless 
perfectly  genuine  ;  but  in  addition  to  the  mode  of  onset,  observe 
the  inconsistencies  of  the  hypergesthesia  itself.  So  great  was  it, 
that  had  it  been  real  and  not  imaginary ,  it  must  have  been 
unbearable  for  the  man  either  to  have  rested  against  his  couch, 
or  even  to  have  borne  the  contact  of  his  clothes. 

This  is  the  hyperaesthesia  so  often  found  superadded  to  the 
pain  which  is  a  real  consequence  of  the  vertebral  sprain ;  and 
yet  too  frequently  the  inconsistencies  thereof  are  ignored,  and  the 
hyper-sensitiveness  is  regarded  as  another,  and  more  telling, 
symptom  of  some  inflammatory  condition  of  the  membranes  of 
the  spinal  cord.  It  has  little  in  common,  however,  with  the 
hypertesthesia  or  the  "  excentric "  pains  which  are  a  result  of 
irritation  of  the  sensory  nerve-roots,  whether  by  thickening  of 
membranes  or  otherwise  ;  and  it  is  unlike  the  zone,  or  girdle 
of  hyperaBsthesia,  which  may  feel  to  the  patient  like  a  cord,  or 
some  other  abnormal  sensation  at  the  periphery.  The  hyper- 
esthesia is  too  widespread  over  one  area,  and  is  at  the  same  time 
too  limited  to  the  area  which  is  the  chief  seat  of  attention.  It 
is,  moreover,  unlikely  that  real  irritation  of  the  sensory  nerve- 
roots  should  give  rise  to  hypergesthesia  upon  the  back  alone.  It  is 
rather  the  natural  outcome  of  that  alarm,  which,  both  in  hospital 
patients  and  in  those  more  especially  who  have  been  in  railway 
collisions,  seems  to  be  inseparable  from  injuries  to  the  spine  or  back; 
and  although  undoubtedly  a  real  condition  to  the  patient  himself,  it 
is  yet  unreal,  and  the  product  of  his  disordered  imagination  alone. 

It  is  hardly  necessary  to  dwell  upon  the  pain  and  local  tender- 
ness of  which  there  is  no  sign  when  the  attention  of  the  patient 
is  otherwise  engaged  and  directed  away  from  the  affected  part. 
These  may  be  of  the  same  nature  as  the  hypergesthesia,  though 
much  more  often  they  have  no  real  existence,  and  are  heard  from 
those  persons  only  who  are  purposely  exaggerating  the  effects  of 


12  RAILWAY    INJURIES. 

the  injuries  they  have  received.  Let  it  be  remembered  that  a  far 
more  important  sign  than  variableness  of  the  pain  under  examina- 
tion, is  the  very  fact  that  the  attention  of  the  patient  can  be  so 
easily  diverted  from  the  affected  part.  Call  to  mind  a  case  of 
severe  inflammation  of  the  knee-joint,  and  ask  whether  it  is  not 
well-nigh  impossible  to  divert  the  patient's  attention  from' his  knee 
when  being  examined,  and  whether  he  does  not  guard  it  with 
all  the  more  conscious  care,  because  he  is  being  asked  questions 
wholly  unconnected  with  the  painful  limb.  The  very  readiness 
with  which  the  attention  can  be  diverted  from  the  tender  back  is 
of  greater  diagnostic  import  than  the  spinal  tenderness  or  pain. 

The  hypergesthesia  and  tenderness  just  alluded  to  are  of  a 
nature  akin  to  the  tenderness  which  is  observed  in  the  cases  of 
so-called  "  spinal  irritation,"  a  malady  with  which  the  brothers 
Griffin  dealt  very  fully  in  1834,  in  their  interesting  and  well- 
known  work,  "  On  Functional  Affections  of  the  Spinal  Cord." 
They  there  point  out  (p.  201)  how  spinal  tenderness  is  a 
"common  attendant  on  all  hysterical  complaints,  on  numerous 
cases  of  functional  disorder  where  the  hysteric  disposition  is  not 
so  obvious,  and  in  many  nervous  or  neuralgic  affections."  The 
tenderness  might  be  both  local  and  general  over  the  spine,  and 
in  their  judgment  it  was  enough  to  throw  doubt  on  any  other 
symptom  suggestive  of  intraspinal  lesion  or  inflammation. 


Peripheral  11.  Passing,  then,  from  the  pain,  tenderness,  stiffness,  and  hyper- 
after  signal  ^sthesia  which  are  the  more  immediate  signs  of  that  kind  of  injury 
injury.  which  the  back  most  frequently  receives  in  collisions,  I  proceed 
in  the  next  place  to  speak  of  other  symptoms  or  complaints 
which  occasionally  accompany  them,  and  which  may  be  regarded 
as  evidence  of  damage  to  structures  other  than  the  bony,  the 
lig-amentous,  and  the  muscular  of  the  vertebral  column. 

And  in  the  consideration  of  them  it  is  necessary  to  bear  in 
mind  that  however  well  the  spine  itself,  and  the  muscles  and  liga- 
ments which  bind  its  various  parts  together,  may  be  adapted  for  pro- 
tecting the  intraspinal  structures  from  injury,  even  at  their  own 
expense,  it  is  simply  a  question  of  the  degree  of  the  violence  whether 
muscles  and  ligaments  are  alone  injured  by  forces  which  tend  to 
overbend  the  spine.  Up  to  a  certain  point  these  soft  structures  may 
succeed  in  keeping  safe  the  parts  within,  even  though  they  them- 
selves may  suffer  in  the  attempt ;  beyond  that  point  their  resistance 
is  overcome,  and  there  may,  as  a  consequence,  be  separation  of 
parts  which  it  is  their  business  to  hold  together.      This    is,   of 


INJUPJES    OF    THE    BACK.  I  3 

course,  much  more  likely  to  happen  when  the  violence  has  fallen 
upon  one  part,  instead  of  being  widely  diffused,  and  a  not  un- 
common way  in  which  the  cord  may  be  locally  damaged,  is  by 
overbendiug  of  the  spine. 

The  pseudo-paralysis  of  muscular  incapacity  has  already  been 
described,  but  abnormal  sensations  of  tingling  1  and  numbness,  or 
of  "  pins  and  needles  "  in  some  parts  of  the  limbs,  are  not  very 
uncommon  after  severe  collisions.  All  such  complaints  ought 
rightly  to  be  regarded  as  worthy  of  attention  and  anxiety,  espe- 
cially if  they  last  for  any  length  of  time  after  the  accident,  or  if  it 
can  be  definitely  asserted  that  the  spine  alone  received  injury. 
It  is  rare,  however,  for  the  injuries  received  in  severe  collisions 
to  be  limited  to  a  single  blow  on  one  part  of  the  spinal  column, 
and  it  is  important  to  determine  whether  these  abnormal  peri- 
pheral sensations  are  not  really  due  to  some  blow  sustained  by 
the  limbs  themselves,  before  deciding  that  they  are  the  manifesta- 
tion of  central  damage.  When  this  obvious  fallacy  has  been 
excluded,  the  remaining  pi'oportion  of  cases  in  which  these  com- 
plaints are  made  is  found  to  be  very  small. 

Case  6. — Severe  general  vertebral  sprain — Sensations  of  numh- 
ness  and  tingling. — E.  H.  D.,  aged  thirty-five,  received  in  a  severe 
collision  "  a  blow,"  as  he  expressed  it,  "  down  his  whole  back,"  and 
also  on  the  back  of  his  head  from  a  falling  carpet-bag.  He  did 
not  consider  himself  much  hurt,  although  from  the  account  of  his 
appearance  there  must  have  been  a  considerable  degree  of  shock. 
He  proceeded  on  his  journey,  but  three-quarters  of  an  hour  after 
the  accident  he  felt  compelled  to  stop  and  go  to  bed  at  a  neigh- 
bouring inn.  He  then  began  to  suffer  from  severe  pain  in  the 
head,  and  from  pain  down  the  whole  of  the  spine,  but  more  especi- 
ally about  the  sacrum  and  the  lower  cervical  region.  There  were 
no  marks  of  bruising.  He  also  complained  of  "  numbness  and 
tingling  "  in  his  limbs,  with  some  difficulty  in  moving  them.  He 
suffered  for  three  days  from  extreme  nervous  prostration  ;  dreaded 
the  least  noise ;  spoke  only  in  a  whisper,  and  lay  in   a  darkened 

^  Abnormal  sensations"  described  as  "tingling"  or  "pins  and  needles"  are, 
although  purely  subjective,  much  more  trustworthy  tenus  than  "  numbness," 
which  the  laity  use  with  a  signification  wholly  different  from  that  in  common  use 
amongst  ourselves.  Dread  of  moving  the  limbs  without  causing  pain,  bodily  weak- 
ness and  stiffness  from  confinement  to  bed,  or  the  sensations  produced  by  general 
bruising  of  the  limbs,  may  each  and  all  be  described  as  "numbness,'  even  when  we 
find,  and  the  patient  admits,  that  there  is  no  real  antesthesia  nor  true  loss  of  mus- 
cular or  sensory  power.  Thus,  for  example,  a  man  described  his  leg  as  feeling 
"numb  "'  after  having  received  a  slight  blow  on  the  side  of  the  knee. 


14  RAILWAY    INJURIES. 

room.  There  was,  however,  no  disturbance  of  pulse  or  tempera- 
ture, and  he  had  been  able  to  sleep  without  narcotic  for  a  few 
hours  on  the  night  after  the  accident.  On  the  following  days 
his  limbs  felt  more  natural,  and  the  tingling  and  sensation  of  numb- 
ness had  very  much  lessened.  In  five  days  these  sensations  had 
completely  disappeared,  but  he  still  suffered  from  much  pain  about 
the  vertebral  column,  and  movements  of  the  neck  and  trunk  were 
painful  to  him.  He  was  excessively  nervous,  and  much  dreaded 
any  examination  of  his  back.  The  pulse  and  temperature  were 
throughout  normal.  He  continued  steadily  to  improve,  and  in 
three  weeks  was  able  to  be  moved.  In  three  months  he  was 
going  out  daily,  walking  slowly  about  three  miles  a  day,  but 
complaining  much — especially  under  examination — of  pain  in 
and  about  his  vertebral  column,  the  movements  of  which  were 
evidently  stiff  and  painful.  He  was  still  very  nervous  and  felt 
generally  weak,  but  there  was  no  impairment  of  motion  or  of 
sensation  in  his  limbs.  He  returned  to  work  in  about  seven 
months.  Five  years  after  the  accident  he  was  at  work  and  in 
good  health,  though  often  complaining  of  his  back,  "  especially 
when  lifting  heavy  weights." 

It  is  obvious  both  from  the  history  at  the  time  and  from  the 
long-continued  pain  afterwards,  that  there  was  here  precisely  the 
same  kind  of  injury,  as  far  as  the  spinal  column  was  affected,  as 
in  the  two  previous  cases,  but  with  the  important  addition  of 
some  abnormal  sensations  in  the  limbs,  coming  on  synchronously 
with  the  pains,  and  disappearing  after  a  few  days.  These  sensa- 
tions were  general,  and  were  not  confined  to  any  one  limb  or 
part  of  a  limb ;  and  although  it  is  impossible  to  define  their 
cause  with  certainty,  there  are  good  grounds  for  believing  them 
to  be  due  to  some  effect  produced  by  strain  or  blow  upon  the 
nerve  trunks  proceeding  from  the  spinal  column  to  the  limbs. 
In  severe  collisions,  where  there  is  a  risk  of  the  body  being 
suddenly  bent  and  strained  in  many  different  directions,  it  is, 
indeed,  highly  probable  that  every  part  of  the  spinal  column  is 
subjected  to  muscular  and  ligamentous  strain,  and  it  is  not  incon- 
ceivable that  the  nerves  which  permeate  the  column  at  both  sides 
should  be  involved  in  the  same  injury. 


Need  for  12.    No  One  will  dispute  the  wisdom  of  absolute  rest  in  all  such 

rest!  "^      cases,   even    though    there    is   no  warrant   for  thinking  that  the 

symptoms  will  be  followed  by   some   less  dubious   indication    of 

central  nerve  lesion.      In   themselves   thev  are  rare,   and   found 


INJURIES    OF    THE    BACK.  I  5 

only  after  the  more  serious  accidents  in  which  there  is  a  risk  of 
extensive  bruising  and  straining  of  the  whole  body.  Whether 
the  result  of  definite  structural  lesion  or  no,  the  symptoms  of 
nerve  disturbance  leave  no  trace  behind  ;  in  other  words,  recovery 
from  the  condition  on  which  they  depend  is  complete :  and 
although  the  2Jf'cccnition  of  absoliUe  rest  is  im^Jcralivc,  there  is  no 
evidence  so  far  to  show  that  they  are  of  more  serious  import  than 
is  the  sensation  of  tingling  in  the  ulnar  distribution  after  a  blow 
upon  the  elbow. 

Their  presence,  however,  does  not  militate  against  the  broad 
conclusion  that  the  spinal  cord  is  veiy  securely  protected  from 
injury  in  its  osseous  canal,  and  that  we  shall  probably  find  more 
definite  symptoms  when  there  has  been  undoubted  lesion  of  the 
marrow  itself.  No  matter  what  be  the  orgaii  or  structure,  the 
severity  of  a  lesion  may  differ  vastly  in  degree,  and  it  may 
perhaps  be  that  these  abnormal  sensations  are  the  symptoms 
of  a  disturbance  which,  in  cases  of  more  obvious  local  injury, 
amounts  to  actual  damage — discoverable  and  giving  rise  to  less 
transient  symptoms — of  the  spinal  cord  or  of  the  nerves  proceed- 
ing from  it. 

The  record,  however,  of  a  large  number  of  injuries  indisputably 
proves  that  the  cases  are  few  and  far  between,  in  which  there 
has  been  unquestionable  lesion  either  of  central  or  more  peripheral 
parts  of  the  nervous  system.  Lesions  of  the  spinal  cord  are  met 
with  only  in  a  few  isolated  cases,  and  it  is  essential  that  this  fact 
should  be  duly  recognised  if  a  right  estimate  is  to  be  formed  of 
the  much  larger  class  of  cases,  in  Avhicli  the  injury  and  symptoms 
are  rather  those  of  general  nervous  shock,  variable  in  degree,  pro- 
tracted in  time,  where  it  may  be  held  by  some  that  there  has 
been  concussion  of  the  spinal  cord,  even  though  there  has  been 
no  evidence  of  blow  upon,  or  of  damage  to,  the  structure  of  any 
one  organ  or  part  of  the  body. 

Case  7, — Severe  liimho- sacral  spraiii — Probable  injury  to  cords 
of  sacral  'plexus. — S.  V.,  aged  forty-eight,  the  mother  of  several 
children,  gave  the  following  account  of  the  injuries  she  received  in 
a  severe  collision  which  occurred  at  night,  and  in  which  a  great 
many  persons  were  hurt.  She  had  no  distinct  remembrance  of 
what  happened  to  her,  but  after  she  had  been  carried  home  and 
put  to  bed,  marks  of  severe  bruising  were  found  between  the  eyes, 
at  the  back  of  the  head,  on  the  chest,  and  more  extensively  about 
the  lumbar  and  sacral  regions  of  the  vertebral  column.  Beyond 
the  bruising  there  were  no  physical  signs  of  injury  to  the  spine. 


I  6  RAILWAY    INJURIES. 

She  was  in  bed  for  three  months,  suffering  chiefly  from  pain  in  her 
back,  so  bad  at  tirst  that  she  could  not  move  in  bed.  She  also 
had  what  she  described  as  a  "  numbing  pain  down  the  left  leg." 
At  the  end  of  three  months  she  was  so  much  better  as  to  be 
able  to  get  out,  and  shortly  after  to  be  moved  to  the  seaside. 
Ten  months  after  the  accident  her  chief  complaints  were  of  pain 
in  the  back,  especially  on  movement,  and  of  a  partial  loss  both 
of  motion  and  sensation  in  the  left  leg.  She  was  then  using 
the  leg  as  much  as  she  could,  though  obliged  to  go  about  with 
crutclies.  There  was  very  slight  wasting  of  the  limb,  all  the 
movements  of  wliich,  it  may  be  said,  were  sluggish  and  defective 
in  power.  There  was  diminution  of  ordinary  sensation,  slight 
only,  but  yet  undoubted.  There  was  no  dragging  of  the  limb 
in  walking,  the  leg  being  rather  held  stiffly,  and  conveying  the 
impression  of  injury  having  been  received  about  the  hip.  There 
could,  indeed,  be  no  doubt  that,  in  addition  to  the  paresis,  there 
was  injury  to  the  muscular  and  ligamentous  structures  about  the 
hip  and  pelvis,  injury  which  led  to  much  of  the  stiffness  about 
the  thigh,  such  as  might  have  been  remedied  by  freer  movement 
than  the  patient  could  give  to  it.  There  was  never  any  paralysis 
of  bladder  or  bowel.  From  the  time  when  this  patient  was  seen 
she  steadily  improved.  Thirteen  months  after  the  accident  she 
was  able  to  abandon  her  crutches,  though  the  report  of  her  then 
was  that  "  sensation  is  still  very  feeble  in  the  injured  leg,  but 
there  is  still  progress  made."  Two  years  later,  or  three  years 
after  the  accident,  this  last  report  was  sent  by  the  surgeon  under 
whose  care  she  had  continuously  been  : — "  The  case  you  saw  two 
years  ago  has  resulted  in  a  complete  cure,  and  she  is  now  able 
to  walk  about  almost  as  well  as  ever." 


Concomi-  13.  It  must,  I  think,  be  regarded  as  very  highly  probable  that 
lesions!'^^^  the  impairment  of  motion  and  sensation  in  this  case  was  due  to 
some  injury  to  the  nerve  trunks,  but  it  is  impossible  to  say  with 
certainty  whether  that  injury  was  after  the  nerves  had  formed 
the  plexuses  outside  the  vertebral  column,  or  when  they  still  were 
individual  cords  in  the  cauda  equina.  If  the  paresis  was  due 
to  traumatic  lesion  of  the  nerve  trunks  within  the  spinal  canal, 
it  is  almost  inconceivable  that  the  effects  could  have  been  con- 
fined to  the  nerves  of  one  limb  only,  and  on  this  ground  it  seems 
more  reasonable  to  conclude  that  the  injury  to  the  nerve  trunks 
was  outside  the  vertebral  column.  The  length  of  time,  moreover, 
that   elapsed   before   the   recovery   of  the  patient,   seems  further 


INJURIES    OF    THE    BACK.  17 

to  confirm  this  opinion,  whether  the  essential  lesion  was  of  the 
nerves  themselves,  or,  as  is  equally  probable  from  the  character  of 
the  blow,  was  haemorrhage  lying  around  and  pressing  upon  them. 

Case  8. — Lumbosacral  sprain — Probable  injury  to,  or  hccmor- 
rhage  round,  pelvic  plexuses. — A  strong  and  healthy  man,  aged 
twenty-nine,  was  thrown  down  on  the  floor  of  the  carriage  in  a 
sharp  collision,  and  knew  that  he  had  had  a  severe  blow  over  the 
right  sacro-iliac  region.  He  almost  directly  afterwards  had  sensa- 
tions of  pins  and  needles  all  over  him.  These  soon  passed  away, 
but  he  was  in  bed  more  or  less  for  four  months,  suffering  from  great 
pain  in  the  lower  part  of  the  back,  and  numbness  and  heaviness 
in  his  legs.  For  three  months  his  pulse  was  as  slow  as  fifty-six. 
Eight  mouths  after  the  accident  he  was  still  quite  unable  to  attend 
to  his  work,  and  suffered  at  times  very  much  from  pain  in  the  back 
and  from  weakness  in  the  legs.  This  weakness  more  especially  in  - 
volved  the  right  leg,  and  although  every  required  movement  could 
be  performed,  it  was  evidently  done  with  difficulty,  and  there  was 
some  impairment  of  common  cutaneous  sensation.  There  was  no 
wasting,  and  the  reflexes  were  normal.  His  gait  was  distinctly 
suggestive  of  lumbar  stiffness,  but  there  was  clearly  in  addition 
some  defect  in  the  innervation  of  his  right  leg ;  and  five  years 
after  the  accident,  although  he  was  well  and  at  his  work,  there 
was  still  said  to  be  pain  about  the  sacrum  and  right  hip,  made 
worse  by  walking  or  long  standing,  and  the  right  leg  was  de- 
scribed as  being  not  as  large  as  the  other.  This  statement, 
however,  there  was  no  opportunity  of  confirming  by  a  medical 
examination,  and  it  must  remain  a  matter  of  doubt  whether  any 
and  what  injury  had  been  incurred  by  the  pelvic  plexuses. 

It  is  never  easy,  in  cases  like  these,  to  separate  the  symptoms 
which  are  due  to  interrupted  or  damaged  nerve  function  from 
those  which  depend  on  muscular,  ligamentous,  and  osseous  bruise 
and  strain.  These  last  may  be  very  severe,  and  may  give  rise 
to  great  mechanical  impairment  of  motor  power,  producing  the 
pseudo-palsy  to  which  earlier  reference  has  been  made  ;  and 
only  a  very  careful  examination  of  the  limb,  and  of  all  the 
attendant  symptoms,  will  enable  one  to  decide  that  there  has  or 
has  not  been  injury  to  nerve  structures.  In  the  great  majority 
of  these  cases  of  general  lumbo-sacral  strain,  they  usually  escape 
direct  injury  ;  but  there  is  no  question  that  this  form  of  traumatic 
lumbago,  due  to  violent  wrench  of  all  the  ligamentous  structures 
of  the  ilium,  sacrum,  and  lower  spine,  of  all  others  is  the  most 
painful  and  the  most  incapacitating,  and  the  pain  is  very  prone 

B 


l8  RAILWAY    INJURIES. 

indeed  to  radiate  widely  from  tlie  part  where  it  has  its  original 
seat.  It  is  by  no  means  unconmion,  in  cases  of  ordinary 
lumbago,  for  the  pain  to  spread  to  the  lower  abdomen,  to  the 
testes,  and  down  the  legs,  but  there  is  no  reason  to  think  that 
the  pain  which  radiates  in  this  way,  whether  in  simple  or  in 
traumatic  lumbago,  is  due  to  any  gross  lesion  in  nervous  struc- 
tures. Help  in  diagnosis  will  always  be  had  by  learning  the 
character  of  the  blow  which  has  been  received  in  the  collision, 
or  the  precise  mode  in  which  injury  has  been  inflicted  upon  the 
back.  My  own  inquiries  and  experience  leave  no  doubt  in  my 
mind  that  any  local  lesion  of  nerve  centres,  or  of  nerve  trunks, 
has  its  origin  in  injuiy  at  or  close  to  the  part,  and  that  the 
general  concussion  of  the  accident  is  inadequate  to  bring  about 
^so  grave  a  result.  The  cases  already  given  exemplify  this,  but 
not  so  markedly  as  the  following. 


Myelitis  14.    Case  9. — Late  myelitis  following  obscure  spinal  injury. — 

ino-itiri.  "  '-T-  L.,  aged  twenty-nine,  a  thin,  delicate  man,  was  in  a  very 
bad  collision  in  which  three  persons  were  killed,  and  in  wdiich  a 
large  number  were  injured.  He  could  give  no  clear  account  ot' 
the  accident,  saying  he  was  dazed  and  could  not  stand.  He 
was  confined  to  bed  for  about  a  fortnight,  suffering  much  from 
pain  in  his  back  and  legs.  He  then  improved  a  little,  and  was 
able  to  go  to  a  hydropathic  establishment  in  the  countr}',  where 
he  stayed  for  two  months.  His  back  continued  to  trouble  him 
very  much  (this  is  in  his  own  words),  but  otherwise  he  improved. 
Towards  the  close  of  this  two  months  the  weakness  which  he 
had  all  along  felt  in  his  legs  became  a  much  more  definite  loss 
of  power,  and  in  a  week  or  ten  days  he  was  quite  unable  to 
walk.  Ten  months  after  the  accident  there  was  no  mistake  as 
to  his  condition.  Loss  of  power  to  move,  and  almost  entire 
loss  of  sensation  in  his  legs,  paralysis  of  bowel,  paralysis  of 
bladder  with  alkaline  urine,  bed  sores,  and  reflex  spasms  of  the 
lower  limbs,  undoubtedly  pointed  to  softening  of  the  spinal  cord. 
His  pulse  was  frequent,  and  his  temperature  above  normal.  He 
complained  of  pain  in  the  lower  part  of  the  back,  but  there  was  no 
marked  tenderness.  He  lingered  for  some  months  without  improve- 
ment, and  then  died. 

It  is  unfortunate  that  no  post-mortem  examination  was  allowed 
in  this  case,  for  it  would  have  been  in  every  way  desirable  to 
have  learned  exactly  the  nature  of  the  injur}-,  if  any,  which  the 
vertebral    column   sustained,  and  how  it  came    to  pass  that   the 


INJURIES    OF    THE    BACK.  1 9 

cord  became  affected.  The  precise  train  of  events  can  therefore 
be  a  matter  of  conjecture  only.  Two  months  elapsed  between 
the  receipt  of  the  injury  and  the  onset  of  definite  symptoms  of 
inflammation  and  softening  of  the  spinal  cord  itself,  and  there  is 
unfortunately  no  more  accurate  record  of  what  his  condition  really 
was  during  this  period.  The  mode  in  which  he  was  injured, 
however,  seems  to  render  it  not  improbable  that  there  were 
symptoms  which  should  have  made  a  fortnight's  stay  in  bed 
altogether  inadequate,  and  so  early  a  move  to  the  country  most 
unwise.  For  the  accident  really  happened  in  this  way,  as  was 
learned  from  another  person  who  was  with  him  at  the  time. 
The  patient  was  thrown  on  his  face  on  the  floor  of  the  carriage, 
and  a  very  "  heavy  man  then  fell  on  the  top  of  him,  right  in 
the  middle  of  his  back."  There  was  thus  no  doubtful  history  of 
a  blow,  of  obscure  injury  to  a  remote  part,  or  of  a  general  shake 
of  the  whole  body,  but  a  clear  account  of  an  accident  so  happen- 
ing, that,  without  any  visible  signs  of  damage  to  the  spine,  there 
may  well  have  been  some  separation  of  vertebrse,  or  some  undue 
bending  of  the  column,  which,  damaging  at  the  same  time  the 
membranes  of  the  cord,  or  causing  slight  intraspinal  heemorrhage, 
was  the  real  starting-point  of  the  mischief  which  supervened. 

I  would  suggest  the  following  as  a  very  probable  sequence  of 
events  : — A  small  localised  injury  of  the  membranes,  or  hjemor- 
rhage,  at  the  site  of  the  injury  to  the  vertebral  column,  followed 
by  a  meningitis  which  was  at  first  too  limited  in  extent  to  give 
rise  to  any  precise  symptoms,  but  which  preceded,  and,  having 
implicated  the  cord,  was  the  cause  of  the  myelitis  which  had  a 
fatal  issue.  If  this  be  the  explanation,  the  meningitis  must  have 
at  first  been  exceedingly  limited,  because  traumatic  meningitis 
does  not  usually  follow  an  unobserved  course.  Sometimes  it  is 
acute,  spreads  rapidly,  gives  rise  to  definite  symptoms,  and  has  a 
fatal  result.  At  other  times  a  less  violent  inflammation  leads  to 
local  thickening  and  adhesion  about  the  spinal  roots,  causing 
peripheral  symptoms  of  impaired  innervation  ;  or  similar  patho- 
logical changes  may  involve  the  cord  itself,  and  setting  up 
degeneration  therein,  present  very  definite  indications  of  struc- 
tural disease.  But  acute  myelitis  at  so  long  an  interval  after 
injury  is  most  uncommon.  Still  further  doubt,  however,  sur- 
rounds this  case,  for  at  the  time  when  the  symptoms  of  spinal 
softening  were  becoming  marked,  the  man  had  epididymitis. 
It  is  true  that  gonorrhoea  was  altogether  denied,  and  that  the 
epididymitis  may  have  been  caused  by  the  frequent  use  of 
the  catheter ;  but  it  is  to   be  remembered  that   myelitis  of  the 


; 


20  EATLWAY    INJURIES. 

cord  may  be  the  result  of  thrombosis  of  the  pelvic  and  vesical 
veins,  a  direct  consequence  of  the  same  urethral  inflammation 
which  had  produced  epididymitis.  It  seems,  therefore,  within  the 
range  of  possibility  that  the  myelitis  and  the  fatal  result  were  not 
due  to  the  injury  at  all. 

I  have  seen  no  case  of  acute  traumatic  meningitis  following 
railway  injury,  nor  any  in  which  I  could  satisfy  myself  of  the 
presence  of  subacute  or  chronic  meningitis  as  the  basis  of  the 
symptoms  of  general  nervous  shock  which  are  frequently  seen 
after  railway  collision,  and  which  will  be  described  in  a  coming 
chapter.  I  have  often  heard  "  subacute  meningitis  "  put  forward 
as  the  cause  of  the  localised  pains  in  the  back  which  are 
common  after  sprains  of  the  vertebral  column,  more  especially 
when  such  pains  have  been  associated  with  general  bodily  weak- 
ness due  to  long  confinement  in  bed  or  in  the  house,  and  with 
the  nervousness  and  emotional  disturbance  which  are  inseparable 
from  severe  shock  to  the  system.  The  history  and  course  of  the 
cases,  however,  and  the  entire  absence  of  the  real  symptoms  to 
which  meningitis  gives  rise,  have  convinced  me  that  no  such 
serious  mischief  could  exist.  For  meningitis  of  the  spinal 
membranes  is  a  serious  organic  lesion,  and  it  is  hard  to  believe 
that  if  subacute  meningitis  of  traumatic  origin  were  as  common 
as  some  would  seem  to  believe  it  to  be  after  collisions,  we  should 
not  much  more  frequently  meet  with  cases  of  meningitis  running 
an  acute  course,  or  with  cases  where  there  is  likewise  degenera- 
tion of  the  spinal  cord. 


Syphilis  15.    Injuries  to  the  cervical  spine   are,  for  obvious  reasons — 

nienin^*it?s.'  ^^^    lesser    strength    and    its    greater    mobility — more    likely   to 

be  followed  by  local  meningitis   than  are  injuries  to   the  lower 

parts   of  the    column ;    but   wherever   the   lesion    be,    it    should 

never   be    forgotten    how    frequently    syphilis  ^    has    a    share    in 

^  See  paper  by  Dr.  Buzzard  on  "Cases  of  Syphilitic  Paraplegia,"  Lancet,  vol. 
i.  1879,  p.  469.  After  detailing  a  case  of  paraplegia,  with  strangely  variegated 
symptoms,  cured  by  anti-syphilitic  remedies,  he  writes  :  "With  the  clear  history  of 
syphilis  before  us,  we  can  well  imagine  that  the  meningitis  was  gummatous,  and  that 
it  probably  involved  especially  the  internal  surface  of  the  dura  mater  (pachymenin- 
gitis), but  extended  also  to  the  contiguous  soft  membranes.  .  .  .  Xote,  also,  that 
there  was  no  tenderness  on  percussing  the  vertebral  spines.  The  absence  of  this 
symptom  is  too  often  regarded  as  being  almost  inconsistent  with  the  e.xistence  of 
serious  lesion  of  the  cord  or  its  coverings.  Nothing  can  well  be  less  founded  in  fact. 
If  we  put  aside  cases  in  which  the  vertebral  column  itself  is  diseased,  we  shall  find 
that  the  existence  of  very  marked  spinal  tenderness  points  strongly  in  the  direction 
of  a  functional  nervous  affection  of  comparatively  little  importance,  and  does  not 
indicate  a  serious  organic  lesion  of  the  spinal  cord." 


INJURIES    OF    THE    BACK.  2  1 

keeping  up  any  chronic  inflammation  of  the  membranes  of  the 
spinal  cord.  In  a  case  under  my  own  observation  not  long  ago, 
the  symptoms  of  a  scattered  meningitis — to  wit,  slight  wasting 
and  partial  loss  both  of  motion  and  sensation  in  the  legs — had 
been  attributed  to  an  injury  to  the  spine  ;  but  as  a  matter  of 
fact  there  was  a  very  distinct  history  of  syphilis,  the  symptoms 
had  more  than  once  been  lessened  and  almost  removed  by  the 
administration  of  anti-syphilitic  remedies,  and  careful  inquiry 
proved  that  the  supposed  injury  was  altogether  trivial.  And 
although,  from  a  medico-legal  point  of  view,  the  presence  of  a 
syphilitic  taint  does  not  debar  the  patient  from  compensation  for 
injuries  received,  such  taint  must  of  necessity  be  acknowledged 
if  we  are  to  form  a  correct  estimate  of  the  probabilities  of  re- 
covery in  any  particular  case. 

Happily  there  is  no  doubt  of  the  exceeding  rarity  of  spinal 
meningitis  as  an  immediate  result  of  localised  injury  to  the  verte- 
bral column.  The  same  remark  applies  with  especial  force  to 
the  results  of  the  injuries  which  have  been  considered  in  the  early 
part  of  this  chapter ;  and  I  know  of  no  case  in  which  meningeal 
inflammation  has  been  caused  by  injury  to  some  part  of  the  body 
remote  from  the  spine. 


16.  While  then  the  victims  of  railway  collision  are  not  by  Risk  of 
any  means  exempted  from  liability  to  suffer  from  any  and  every  spinal  Loni 
form  of  lesion  of  the  spinal  cord  and  its  membranous  coverings,  ^^fj^"'""''^" 
accumulated  experience  leaves  no  longer  any  doubt  that  these 
grave  results  are  most  uncommon,  and  that  though  the  back 
is  especially  prone  to  suffer  injury  in  this  form  of  accident,  it 
is  the  extra-spinal  structures  which,  in  ninety-nine  cases  out  of 
a  hundred,  bear  the  brunt  of  the  violence  and  suffer  from  it. 
Such  is  the  immediate  consequence,  but  in  every  medico-legal 
inquiry  the  future  as  well  as  the  present  has  to  be  considered. 
What  is  the  prognosis  ;  and  what  risk  is  there  that  after  the 
receipt  of  some  such  obscure  injury  of  the  back  as  we  have  been 
dealing  with,  there  shall  supervene,  as  a  consequence  of  the 
injury,  the  symptoms  of  degeneration  of  the  spinal  cord  ?  No 
more  vital  question  can  be  asked  in  treating  of  railway  injuries. 
It  has  from  the  first  engaged  my  very  careful  attention,  and  I  have 

^  "Inasmuch,"  says  Dr.  Ross  (Diseases  of  the  Nervous  System,  2nd  ed.,  vol.  i. 
p.  293),  "as  there  is  no  severe  organic  disease  affecting  the  nervous  system  in  which 
the  results  of  treatment  are  so  often  satisfactory,  so  there  is  no  disease  which  de- 
servedly brings  so  much  discredit  upon  the  practitioner  who  overlooks  its  presence." 


2  2  RAILWAY    INJUHIES. 

endeavoured  to  learn  of  cases  where  there  has  been  degeneration 
of  the  spinal  cord  as  a  remote  consequence  of  spinal  injury.  My 
inquiries  have  either  been  singularly  unsuccessful — and  they  have 
been  made  by  direct  oral  and  written  communication  with  many 
professional  brethren  in  all  parts  of  the  country — or  it  must  be 
admitted  that  secondary  and  remote  degeneration  of  the  spinal 
cord,  in  cases  where  there  has  been  no  distinctive  evidence  of 
injury,  is  very  rare  indeed.  Nor  have  I  been  able  to  discover 
any  grounds  for  thinking  that  the  injured  in  railway  collisions, 
numbering  many  thousands  since  the  first  accident  happened, 
have  afforded  a  larger  projoortion  of  those  degenerative  system- 
diseases  of  the  spinal  cord,  which  in  recent  years  have  so 
much  engaged  the  attention  of  neurologists  and  pathologists, 
than  have  those  persons  who  have  not  been  exposed  to  the  same 
influences.  It  is  perfectly  true  that  in  some  recorded  cases  the 
onset  of  a  system-disease  has  had  no  more  obvious  cause 
than  injury,  and  there  is  nothing  inherently  improbable  in  such 
a  sequence  of  events  ;  but  cases  of  the  kind  are  wholly  excep- 
tional, and  are  too  few  in  number  to  call  for  the  introduction 
of  any  account  of  them  in  a  chapter  devoted  only  to  the 
common  and  everyday  forms  of  spinal  injury  as  seen  after 
collision  accidents. 


Associated  17.  A  Survey  has  thus  far  been  taken  of  the  common  spinal 
thenfa'and  i'^j^^'^'ies  of  railway  collisions,  but  there  is  nothing  in  all  that 
theinflu-     Jias  been  said  to  sugofest  that  these  iniuries  differ  in  anv  way 

ence  of  ....  .  .  .  *  . 

compensa-  from  Spinal  injuries  received  in  other  forms  of  accident.  Their 
recovery,  frequency  is,  however,  unquestionable  ;  and  this,  as  we  have  seen, 
is  due  to  the  special  nature  of  railway  collisions,  whereby  the 
back  is  very  liable  to  be  spi-ained.  Given  a  case  in  which  a  mere 
sprain  of  the  back  is  the  only  injury  sustained,  there  is  not,  and 
there  ought  not  to  be,  much  difficulty  in  diagnosis  ;  but  again,  the 
nature  of  a  railway  collision  determines  a  liability  to  other  forms 
of  health  disturbance,  which,  in  company  with  a  spinal  sprain, 
may  make  the  diagnosis  far  from  easy,  and  may  be  the  source  of 
needless  alarm.  Here  step  in  to  perplex  the  clinical  inquirer 
those  so-called  functional,  emotional,  and  hysterical  disorders, 
which  have  yet  to  be  considered,  which  are  really  due  to  the 
fright  and  mental  shock  incidental  to  railway  accidents,  but 
which  have  been  too  often  looked  upon  as  the  result  of  injury  to 
the  spinal  membranes  or  the  spinal  cord.  Here  also  in  very 
common    association    are    the    symptoms    due    to    severe   general 


INJURIES    OF    THE    BACK.  23 

nervous  shock,  whicli  are  seen  even  when  tliere  has  been  no 
evidence  of  injury  to  any  one  organ  of  the  body,  or  of  a  blow 
having  been  inflicted  on  any  single  part.  They  may  come  on  soon 
after  the  accident,  or  be  delayed  for  many  hours  ;  they  are  charac- 
terised by  enfeebled  function  both  of  body  and  mind,  and  are  not 
uncommon  in  those  who  have  received  no  bodily  injury  whatever. 
As  I  shall  have  to  point  out,  they  are  the  continued  expres- 
sion of  severe  nervous  exhaustion.  Picture  a  case  of  this  kind, 
and  add  to  it  sprain  of  the  muscles  and  ligaments  of  the  vertebral 
column,  with  the  resultant  pain  on  movement,  so  obstinate  in  its 
duration,  and  the  tenderness — sometimes  acute — on  touch,  and 
it  is  neither  more  nor  less  than  natural — though  a  natural 
mistake — that  the  whole  condition  should  be  attributed  to  some 
alteration  or  morbid  change  of  the  spine  and  spinal  cord  which 
have  been  concussed. 

The  jar  or  vibration  of  a  collision  must  doubtless  shake  the 
spinal  cord  as  much  as  the  brain  and  every  other  organ  of  the 
body,  but  there  is  scant  reason  for  an  explanation  of  the  symptoms 
of  general  nervous  shock  in  degenerative  changes  of  the  structures 
lying  within  the  spinal  canal,  simply  because  the  patient  has  a 
painful,  stiff,  and  tender  back.  However  alarming  such  cases 
may  be,  the  tendency  is  towards  perfect  recovery  after  a  longer 
or  a  shorter  time.  And,  inconsistent  though  it  may  at  first  sight 
appear  that  anything  apart  from  the  injury  and  the  bodily  con- 
dition itself  should  influence  convalescence,  it  is  none  the  less  a 
fact,  which  daily  experience  confirms,  that  the  period  of  I'ecovery 
very  frequently  begins  at  the  moment  when  all  mental  anxiety 
and  worry  are  at  an  end  as  to  the  legal  aspects  of  the  case.  The 
settlement  of  the  patient's  claim  for  compensation  has  a  potent 
influence  in  bringing  about  convalescence,  not  necessarily  because 
tliere  has  been  imposture  or  a  lack  of  perfect  genuineness  in  the 
facts  and  features  of  the  case,  but  because,  as  a  very  symptom 
of  the  malady  itself,  there  must  have  been  an  inability  to  bear 
the  strain  of  a  medico-legal  inquiry.  The  strain  removed,  the 
anxiety  lessened,  there  is  nothing  now  in  the  way  of  a  hopeful 
effort  being  made  to  return  to  a  more  natural  and  healthful  mode 
of  life,  and  each  returning  day  of  improved  mental  tone  forges 
one  more  link  in  the  chain  of  progress  towards  recovery.  I  am 
not  referring  here,  be  it  remembered,  to  cases  which  are  not 
strictly  genuine,  and  where  there  is  grave  reason  for  suspecting 
the  lona  fides  of  the  patient.  Examples  of  this  kind  are  not  un- 
common, where  the  prospect  of  larger  pecuniary  gain  acts  as  a 
temptation  to  keep  up  the  invalid  state ;  but  we  must  be  careful 


24  RAILWAY    INJURIES. 

that  the  absence  of  objective  signs  of  nerve  lesion  does  not  lead 
us  into  the  error  of  throwing  doubt  on  the  integrity  and  veracity 
of  those  who  are  really  suffering  from  the  symptoms  of  general 
nervous  shock.  There  is  a  vast  difference,  however,  between  the 
false  and  the  true,  and  the  one  can  be  distinguished  from  the 
other  without  much  difficulty. 


CHAPTER  11. 

GENERAL  NERVOUS  SHOCK. 

Summary. —  l.  Nature  and  signs  of  shock  or  collapse. — 2.  Fright  a  potent  cause, 
especially  in  railway  accidents. — 3,  Delayed  symptoms. — 4.  Different  degrees  of 
shock. — 5.  Neurasthenia  different  from  hysteria,  but  often  associated  with  it. 
—  6.  Tliorburn's  classification.  —  7.  Symptoms  of  protracted  nervous  shock  : 
Sleeplessness. — 8.  Disturbances  of  the  circulation. — 9.  Headache. — 10.  General 
nervousness. — 11.  Sweating,  polyuria,  menorrhagia,  diarrhoea. — 12.  Defects  of 
vision  and  size  of  the  pupil. — 13.  The  optic  discs. — 14.  Loss  of  memory,  so-called. 
— 15.  Catamenial  derangements  and  pregnancy. — 16.  The  genito-urinary  system. 
— 17.  Disorders  of  digestion  and  nutrition. — 18.  Prognosis  and  exceptions  to 
the  usual  rule. — 19.  The  complex  of  symptonis. 

1.   Having  thus  far  given  an  account  of  the  injuries  of  the  back  Nature  and 
which   are  commonly  met  with   after  railway  collisions,  my  next  sjf^"ck'or 
duty  is  to  turn   to   the  cases   vastly   more  numerous,   and  even  collapse, 
more  important,  to  which  I    have    already  referred    under  the 
name  "  general  nervous  shock."      This  term   is  applicable  rather 
to  the  whole  clinical  circumstances  of  the  case  than  to  any  one 
symptom  which  may  be   presented   by  the  injured  person.     It  is 
a  phrase  which,  in  its  very  lack  of  precision,  appears   suitable  to 
describe  the  class  of  cases  which  Ave   must  now  consider ;   for  we 
shall  see  that  the  course,  history,  and  general  symptoms  indicate 
some  functional  or  dynamic  disturbance  of  the  nervous  equilibrium 
or  tone,  rather  than  structural  damage  to  any  organ  of  the  body. 

We  are  all  familiar  with  the  term  "  shock "  as  synonymous 
with  the  collapse  which  accompanies  all  profound  and  sudden 
injuries,  whether  inflicted  upon  the  head  or  upon  some  other  part 
of  the  body.  And  this  collapse  or  shock  we  are  wont  to  regard 
as  the  immediate  expression  of  lowered,  or  annihilated,  function 
of  the  great  nerve  centres  which  preside  over  the  vascular  system  ; 
paresis  of  the  heart  and  of  the  peripheral  parts  of  the  circulation 
being  the  essential  factor  in  inducing  the  pallor  and  coldness 
which  affect  the  whole  surface  of  the  body,  and  the  mental 
enfeeblement  which  is  due  to  impaired  flow  of  blood  within 
the  brain. 

This,  however,  is  not  the   place   to  enter  into  any  lengthened 


2  6  RAILWAY    INJURIES. 

description  of  the  nature  of  true  shock  or  coHapse.^  No  matter 
how  the  injury  may  have  been  inflicted,  provided  only  it  has  been 
sudden  and  severe,  wliether  by  railway  accident  or  by  the  more 
ordinary  casualties  of  everyday  life,  shock  or  collapse  in  greater 
or  lesser  desfree  is  invariablv  recognised  as  one  of  the  features 
of  the  patient's  general  condition  immediately  after  the  injury  has 
been  received.  The  collapse  may  be  lasting  and  profound,  or  it 
may  be  slight  and  transient,  but  in  every  case  it  is  an  immediate 
consequence  of  the  injury,  which,  by  its  suddenness  and  severity, 
has  induced  the  paresis  which  primarily  affects  the  great  central 
organ  of  the  circulation.  Nor  need  any  description  be  given  of 
the  history  and  symptoms  of  cases  of  shock  or  collapse,  with  which 
all  are  doubtless  familiar  in  hospital  practice.  There  is,  in  fact,  no 
condition  which  is  more  obvious  or  more  striking  than  that  of  the 
seeming  lifelessness,  which  is  an  indication  that  some  severe  im- 
pression has  been  made  by  injury  upon  the  nervous  system. 

The  term  "  lifelessness  "  is  indeed  an  appropriate  one  to  give 
to  the  state  of  shock  from  injury  in  its  more  serious  degrees. 
There  is  a  lowering  of  the  vitality  of  every  organ  and  function 
of  the  body,  from  mental  activity  and  capacity  to  that  of  the  least 
important  function  in  the  animal  economy.  And  that  which 
probably  lies  at  the  very  foundation  of  many  of  the  sj'mptoms 
of  shock  or  collapse  is  temporary  paresis  of  the  heart,  and  of  the 
whole  circulatory  system.  The  slow,  feeble,  or  almost  annihilated 
pulse,  the  pallor  of  the  lips  and  coldness  of  the  extremities,  the 
mental  hebetude,  the  anaesthesia  of  the  surface,  the  relaxation  of 
the  sphincters,  the  lessened  secretion  of  the  urine,  the  impaired 
muscular  action,  each  and  all  are  dependent  in  varying  degrees 
on  the  paresis  of  the  heart  and  vascular  system,  and  on  the 
impression  upon  the  whole  nervous  system  of  which  that  is  the 
first  and  most  immediate  result. 

The  collapse  may  be  so  profound  as  to  be  a  source  of  greater 
danger  to  the  patient  than  the  bodily  injury  which  he  has  sustained. 
The  issue  may  be  rapidly  fatal,  although  death  is  the  exceptional 
rather  than  the  usual  result  of  uncomplicated  shock.  The  heart, 
under  the  appropriate  treatment  of  quietude  and  warmth — mas- 
terly inactivity — or  if  need  be,  of  stimulants — alcohol,  strych- 
nine, and  digitalis — regains  its  normal  power,  and  the  functions 
are  once  more  naturally  performed.  The  collapse  is  frequently 
succeeded  by  a  period  of  "  reaction,"  in  which  the  temperature  and 

*  Mr.  Savory's  article  in  Holmes'  System  is  known  to  every  one,  and  in  Gi-oeningen's 
Ueber  den  Shock  will  be  found  a  full  account  of  all  the  symptoms  and  of  every  theory 
upon  it. 


GENERAL  NERVOUS  SHOCK.  2/ 

pulse  are  slightly  raised  until  the  equilibrium  of  health  has  been 
established  ;  but  whether  there  be  reaction  or  no,  the  symptoms 
pass  away,  and  except  as  an  indication  for  treatment,  as  a  rule, 
they  give  us  little  more  concern.  Patient  and  surgeon  are  far 
more  interested,  after  the  subsidence  of  the  initial  collapse  and 
its  incidental  risks,  in  the  successful  issue  of  the  needful  opera- 
tion, or  in  the  usefulness  restored  to  the  limb  or  organ  which 
has  been  damaged.  If  these  results  be  satisfactory,  the  patient 
leaves  the  hospital  gratified  at  the  recovery  which  he  has  made, 
and  thankful  perhaps  that  his  injuries  were  not  more  severe. 
What  has  become  of  the  collapse  which  on  his  admission  into 
hospital  was  a  striking  feature  in  his  case  ?  Has  it  no  after- 
symptoms,  or  has  it,  as  we  thought  it  had,  completely  passed 
away  ?  Important  questions  these  ;  but  as  a  matter  of  fact  we 
know  so  little  of  the  after-history  of  hospital  patients,  that  from 
their  cases  we  can  draw  but  little  help  in  elucidation  of  the 
general  nervous  shock  which  is  met  with  after  railway  collisions, 
and  whose  after- symptoms  may  perhaps  be  far  more  prominent 
than  those  which  immediately  followed  the  injury.  Our  hospital 
patients,  as  we  believe,  recover,  and  rarely  or  never  do  we  hear 
of  the  symptoms,  nor  do  we  meet  with  the  class  of  cases  to 
which  I  shall  direct  attention  now. 


2.    Surgeons  are  pretty  well  agreed  that  the  collapse  in  cases  Fright  a 
of    accident    brought    into    hospital    is    usually    very    profound  cause, 
after  the  injuries — crush  of  limbs,  for  example — which  railway  ?^^^.^15'^!^\ 
servants    meet    with    at   their  work,   and   which   often    call  for  accidents. 
operative  interference.     Compare   two  cases  of  like   injury,   the 
one    received    by    accident    on    a    railway,    and    the    other    by 
being  knocked  down  and  run  over  in  the  street,  and  there  is 
great  probability  that  the  manifestations  of  shock  will  be  much 
more    marked    in    the   former    case    than    in    the    latter.      The 
difference   I    believe   is   this,    that  in  the  one    case  there   is  an 
element  of  great  fear  and  alarm,  which  has  perhaps  been  alto- 
gether absent  from  the  less  formidable  and  less  terrible  mode 
of  accident.      How  largely  fright  may  of  itself  conduce  to  the 
condition  recognised  as  shock  is  well  shown  by  a  case  communi- 
cated to  me  by  a  surgeon  of  large  experience,  who,  summoned 
to  a  railway  station  to  see  and  conduct  to  the  hospital  a  railway 
servant  who  had  had  his  foot,  as  was  supposed,  run  over  on  the 
line,  found  him  in  a  state  of  collapse,  and  in  greatest  alarm  as  to 
the  injury  to  his  limb.      Upon  examination  it  was  discovered  that 


2  8  RAILWAY    INJURIES. 

the  only  damage  was  the  dexterous  removal  of  the  heel  of  his 
boot  by  the  wheel  of  a  passing  engine.  And  medical  literature 
abounds  with  cases  where  the  gravest  disturbances  of  function, 
and  even  death  or  the  annihilation  of  function,  have  been  pro- 
duced by  fright  and  by  fright  alone. 

It  is  this  element  of  fear,  this  great  mental  shock,  which  in 
railway  collisions  has  so  large  a  share — in  many  cases  the  only 
share — in  inducing  immediate  collapse,  and  in  giving  rise  to 
those  after-symptoms  which  may  be  almost  as  serious  as,  and 
are  certainly  far  more  troublesome  than,  those  which  we  meet 
with  shortly  after  the  accident  has  occurred.  The  reasons  for 
this  are  not  far  to  seek.  The  incidents  indeed  of  almost  every 
railway  collision  are  quite  sufficient — even  if  no  bodily  injury 
is  inflicted — to  produce  a  very  serious  effect  upon  the  mind,  and 
to  be  the  means  of  bringing  about  a  state  of  collapse  from  fright, 
and  from  fright  only.  The  suddenness  of  the  accident,  which 
comes  without  warning,  or  with  a  warning  which  only  reveals 
the  utter  helplessness  of  the  traveller,  the  loud  noise,  the  hope- 
less confusion,  the  cries  of  those  who  are  injured  ;  these  in 
themselves,  and  more  especially  if  they  occur  at  night  or  in  the 
dark,  are  surely  adequate  to  produce  a  profound  impression 
upon  the  nervous  system,  and,  even  if  they  caused  no  marked 
shock  or  collapse  at  the  time,  to  induce  a  series  of  nervous 
disturbances  at  no  distant  date.  "The  principal  feature  in/' 
railway  injuries,"  says  Mr.  Furneaux  Jordan,  "  is  the  combina- 
tion of  the  psychical  and  corporeal  elements  in  the  causation 
of  shock,  in  such  a  manner  that  the  former  or  psychical  element 
is  always  present  in  its  most  intense  and  violent  form.  The 
incidents  of  a  railway  accident  contribute  to  form  a  combination  ' 
of  the  most  terrible  circumstances  which  it  is  possible  for  the 
mind  to  conceive.  The  vastness  of  the  destructive  forces,  the 
magnitude  of  the  results,  the  imminent  danger  to  the  lives  of 
numbers  of  human  beings,  and  the  hopelessness  of  escape  from 
the  danger,  give  rise  to  emotions  which  in  themselves  are  quite 
sufficient  to  produce  shock,  or  even  death  itself,  ....  All 
that  the  most  powerful  impression  on  the  nervous  system  can 
effect,  is  effected  in  a  railway  accident,  and  this  quite  irrespec- 
tively of  the  extent  or  importance  of  the  bodily  injury."  ^ 


Delayed  3.   In  these  purely  psychical  causes  lies,  I  believe,  the  expla- 

symptoms.  .  c      i  t    \  ^        f  r»  •^  n-   •  i 

nation  or    the   remarkable    iact  that  aiter  railway  collisions  the 

^  Surgical  Enquiries,  2nd  edit.,  p.  37. 


GENERAL  NERVOUS  SHOCK.  29 

symptoms  of  general  nervous  shock  are  so  common,  and  some- 
times so  severe,  in  those  who  have  received  no  bodily  injury,  or 
who  have  presented  little  sign  of  collapse  at  the  time  of  the 
accident.  The  collapse  from  severe  bodily  injury  is  coincident 
with  the  injury  itself,  or  with  the  immediate  results  of  it,  but 
when  the  shock  is  produced  by  purely  mental  causes  the  mani- 
festations thereof  may  be  both  prolonged  and  delayed.  Warded 
off  in  the  first  place  by  the  excitement  of  the  scene,  the  shock 
is  gathering,  in  the  very  delay  itself,  new  force  from  the  fact 
that  the  sources  of  alarm  are  continuous,  that  they  may  recur  for 
days,  and  for  a  time  be  all  potent  for  evil  in  the  patient's  mind; 
"  In  certain  temperaments,  wrought  into  a  state  of  extreme 
excitement,  a  comparatively  severe  injur}'  may  not  be  attended 
with  that  degree  of  shock  which,  under  other  circumstances, 
would  be  seen.  In  those  cases,  however,  shock  is  usually  deferred, 
and  not  altogether  averted  ;  and  it  may  be  all  the  more  severe, 
seeing  that  reactionary  mental  exhaustion,  itself  a  kind  of  shock, 
is  superadded  to  the  effects  of  bodily  injury."  ^ 

Due  weight  must,  therefore,  be  given  to  alarm  and  profound 
mental  emotion  as  causes  of  the  symptoms  of  general  nervous 
shock  so  frequently  seen  after  railway  collisions.  Sufficient  im- 
portance, indeed,  has  not  been  attached  to  them,  and  many  errors 
in  diagnosis  have  been  made,  because  fright  has  not  been  deemed 
of  itself  sufficient  to  bring  about  the  train  of  symptoms  which 
will  be  described.  On  the  one  hand,  we  may  hear  the  condition 
regarded  as  evidence  of  serious  and  irremediable  pathological 
change  in  the  chief  centres  of  the  nervous  system  ;  and  on  the 
other  hand,  no  clear  histor}'  of  pronounced  shock  or  collapse  at 
the  time  of  the  injury  being  forthcoming,  the  symptoms  are 
deemed  unreal,  and  the  bona  fides  of  the  patient  is  called  in 
question.  The  mistakes  are  at  opposite  ends,  and  I  hardly  know 
which  is  the  worse  for  the  patient,  who,  really  suffering  and  ill, 
lies  in  the  condition  in  which  we  find  him  because  his  whole 
nervous  system  has  received  a  shock,  not  so  much  from  severe 
bodily  injury  which  shows  itself  in  unmistakable  signs,  as  from 
the  impalpable  element  of  alarm,  which  has  to  be  measured  by  the 
events  of  the  accident  itself,  and  by  the  temperament  of  the 
individual  who  has  been  affected  therebv. 


4.  The  indications  of  collapse  at  the  time  of  accident  are  very  Diflferent 
variable.      The  profoundest  grades  are  occasionally  seen  after  the  gj^fek^^  ^ 
^  Furneaux  Jordan,  oj>.  cit.,  p.  27. 


30  RAILWAY    INJURIES. 

worst  accidents,  wliere  there  has  been  in  all  probability  destruc- 
tion of  life  and  limb.  In  these  circumstances  it  is  no  marvel 
that  we  should  meet  with  examples  of  most  alarming  collapse, 
associated  with  definite  structural  injury,  an  injury  such  as  would 
be  commonly  marked  by  collapse,  however  and  wherever  it  had 
been  received.  The  collapse,  however,  which  in  these  railway 
accidents  accompanies  serious  bodily  injury,  such  as  laceration  of 
limb  or  fracture  of  bones — always  excepting  the  collapse  from 
severe  concussion  of  the  brain — is  very  rarely  followed  by  the 
train  of  after-symptoms  indicative  of  general  nervous  shock. 
This  is  a  fact  of  great  interest  and  importance,  which  will 
help  to  throw  light  upon  those  symptoms  of  general  nervous 
shock  which  are  often  seen  after  the  slighter  degrees  of  initial 
collapse. 
q/  More  numerous  than  the  cases  of  profound  immediate  collapse 
j  are  those  where  the  accident  has  been  less  severe  in  its  effects 
upon  life  and  limb,  and  where  the  earliest  signs  of  shock  have 
been  comparatively  slight.  "  I  was  thrown  forwards  and  back- 
wards in  the  carriage  ;  I  felt  myself  shaken,  but  did  not  think  I 
had  been  much  hurt ;  I  got  out  of  the  carriage,  and  was  able  to 
help  some  of  the  other  passengers,  and  I  came  on  home  by  the 
next  train :  " — such  is  perhaps  the  simple  story  of  the  man  who 
finds  himself  in  a  few  hours,  it  may  be  only  after  two  or  three 
days,  compelled  to  take  to  his  bed  because  he  feels  so  unnerved, 
and  shaken,  and  ill.  You  make  inquiry  as  to  the  more  immediate 
effects  of  the  accident  upon  him,  and  you  perhaps  learn  that  he 
felt  shaken  and  was  obliged  to  have  some  brandy,  that  he  felt 
sick  and  faint  for  a  few  moments,  or  that  he  even  vomited.  He 
thought  little  of  it,  however,  and  gave  help  to  others.  A  few 
hours  elapse,  and  he  finds  he  cannot  sleep  ;  he  has  aches  and 
pains  in  various  parts  of  the  body,  most  likely  in  the  back  ;  he 
feels  as  if  he  had  been  beaten  all  over  ;  he  is  thirsty,  feverish, 
and  ill ;  and,  gathering  fresh  alarm  from  the  very  fact  that  he 
thought  he  had  happily  escaped  all  injury,  he  sends  for  his 
doctor,  who  sees  that  the  symptoms  of  nervous  disturbance  and 
prostration  have  already  begun.  The  prominent  symptoms,  how- 
ever, do  not  always  arise  so  soon.  Conscious  that  he  has  sustained 
no  bodily  injury,  the  man  continues  at  his  work,  and  days  go  by 
before  it  is  brought  home  to  him  that  he  is  not  so  ready  or  active 
at  his  business,  that  he  is  soon  tired,  and  has  to  leave  off  and  lie 
down  in  the  middle  of  the  day.  It  is  an  increasing  worry  and 
annoyance  to  him  to  write  his  letters,  or  to  talk  with  people  on 
business  affairs ;  the  back  of  his  head  feels  heavy,  and  his  appetite 


GENERAL  NERVOUS  SHOCK.  31 

deserts  him.  Nevertheless  he  struggles  on,  each  day  not  feelinti" 
quite  as  well  as  on  the  day  before,  until  at  last  the  necessity  is 
forced  upon  him  of  completely  abstaining  from  his  work.  With 
varied  modifications  in  detail,  such  stories  as  these  are  often  heard 
of  the  effects  which  an  accident  has  had  on  numbers  of  persons. 
It  is  clear,  from  what  happened  at  the  time,  and  from  the  early 
symptoms  of  reaction  afterwards,  that  there  was  undoubted  shock 
immediately  after,  or  within  a  short  time  of,  the  accident.  Its 
early  manifestations  were  slight,  and  were  disregarded  as  little 
more  than  a  feeling  of  i'aintness  or  of  being  dazed,  but  it  was 
enough  to  show  that  the  alarm  of  the  accident  produced  an  in- 
stantaneous or  early  result,  and  to  be  the  starting-point  of  that 
disturbance  of  the  nervous  system  which  may  assume  an  aggra- 
vated form,  and  continue  for  a  very  long  time.  It  will  be  one 
aim  of  this  work  to  explain  how  it  is  that  the  after-results  of 
even  very  trifling  initial  shock  from  railway  accident  are  often 
more  lasting  and  serious,  than  are  the  later  nervous  symptoms 
of  those  in  whom  the  early  collapse,  with  extensive  bodily  injury, 
was  originally  more  profound. 

Lastly,  at  the  other  end  of  the  scale  are  the  cases  where  there 
is  no  evidence  whatever  of  injury  or  of  collapse,  no  faintness, 
nausea,  or  vomiting,  no  early  reaction  from  an  initial  stage  of 
depression,  but  where  the  after-history  very  closely  simulates  that 
of  the  more  numerous  cases  which  fall  under  our  care.  These 
I  shall  consider  by-and-by,  for  few  are  commoner  than  cases  of 
spurious  nervous  shock. 

Let  me  now  illustrate  the  kinds  of  symptoms  with  which  we 
have  to  deal. 

Case  10. — Severe  general  nervous  shock — Prolonged  symptoms — 
Physical  injuries  slight. — S.  W.,  aged  forty-six,  a  tall,  somewhat 
powerful  man,  was  in  a  very  severe  and  destructive  collision.  He 
received  bruises  over  both  arms  and  legs,  and  also  a  blow  upon 
the  face  which  abraded  the  skin  over,  and  fractured  the  bones  of, 
his  nose.  He  was  not  stunned.  He  lay  for  several  days  after  the 
accident  in  a  state  of  great  nervous  depression,  with  feeble  and 
rapid  pulse,  and  inability  to  eat  or  sleep.  He  suffered  at  the  same 
time  much  distress  from  the  fact  that  a  friend  sitting  beside  him 
in  the  carriage  had  been  killed  ;  and  this  seemed  to  prey  con- 
stantly upon  his  mind.  The  bodily  injuries  proceeded  rapidly 
towards  recovery,  and  in  seventeen  days  after  the  accident  he  was 
able  to  be  moved  home.  Nine  weeks  after  the  accident  he  had 
fairly  well  recovered  from   his  local  injuries,  and  made  no  com- 


32  RAILWAY   INJURIES. 

plaint  of  bodily  sufferings.  Examination  at  this  date  discovered 
no  structural  disease,  but  he  was  evidently  in  a  most  feeble  and 
wretched  state.  The  ordinary  functions  of  the  body  were  natural, 
but  his  mental  condition  showed  extreme  emotional  disturbance. 
He  complained  that  he  had  suffered  continuously  from  depression 
of  spirits,  as  if  some  great  trouble  were  impending.  "  He  is  easily 
upset  and  prone  to  cry.  He  says  he  used  to  cry  whenever  he 
spoke  to  any  one,  but  that  now  he  has  rather  more  control. 
He  has  been  out  of  doors  for  a  few  yards,  but  was  stopped  by 
a  sudden  sensation  as  if  his  breathing  were  very  sliort.  His 
voice  is  very  weak  and  indistinct,  and  occasionally  he  says  it  is 
almost  inaudible.  There  is  no  disease  of  the  larynx  or  adjoining 
parts.  He  sleeps  very  badly,  waking  frequently,  and  being  con- 
stantly troubled  by  distressing  dreams.  His  pulse  is  weak,  104. 
He  occupies  himself  by  a  little  reading  and  by  occasionally  going 
out,  but  he  feels  so  shaken  and  weak  that  he  is  unable  to  do  any- 
thing more.  In  many  respects,  however,  he  is  improving.  The 
weight  he  lost  is  being  regained.  He  can  walk  rather  further,  is 
not  so  ready  to  cry,  and  his  voice  is  stronger."  He  remained  in  much 
the  same  condition  for  several  months,  though  with  undoubted  ten- 
dency toward  improvement.  Fifteen  months  after  the  accident, 
several  months,  that  is,  after  his  claim  had  been  settled,  I  learned 
that  he  was  better,  though  yet  very  far  from  right,  and  he  was  con- 
sidered wholly  unfit  for  work.  His  history,  given  four  years  after  the 
accident  by  his  medical  attendant,  is  as  follows  : — "  In  my  opinion 
he  will  never  be  anything  like  the  same  man  again.  His  appear- 
ance is  much  altered.  He  looks  much  older,  haggard,  and  has 
become  very  bald.  His  voice  is  very  weak,  almost  gone  at  times. 
For  some  time  he  went  about  in  search  of  health,  but  improved 
very  slowly,  if  at  all.  Lately  he  has  obtained  two  posts,  the  work 
at  which  is  of  a  very  light  nature.  I  just  jotted  down  the  follow- 
ing symptoms  as  he  mentioned  them,  and  I  feel  sure  he  would 
not  wilfully  exaggerate  them.  Very  depressed  spirits,  sometimes 
palpitation,  loss  of  sleep,  bad  dreams,  very  easily  tired,  can't  walk 
more  than  two  miles,  then  gets  very  tired  and  quite  loses  his 
voice.  Did  nothing  for  two  years  after  the  accident.  Has  lost 
all  his  energy.  Sometimes  has  a  great  dread  of  impending  evil. 
He  can  travel  by  railway  without  feeling  nervous,  but  can't  drive 
without  feeling  frightened  all  the  time.  I  may  add  that  his 
heart  sounds  are  rather  feeble,  but  not  otherwise  abnormal.  Pulse 
72.  No  special  spinal  symptoms;  no  paralysis;  no  bladder 
symptoms  ;  always  gets  much  upset  if  dining  in  company  or  if 
many  people  are  talking  near  him.      I  knew  him  well  before  the 


GKNERAL  NERVOUS  SHOCK.  3  3 

accident,  and  he  was  a  very  energetic  and  very  honourable 
man."  Three  years  later  hia  symptoms  were  still  subsiding. 
Since  he  began  regular  work  he  had  continued  more  markedly 
to  improve. 

It  must  be  pretty  obvious  from  his  history  that  this  man's 
prolonged  illness  was  due  in  only  small  measure  to  the  hoclily 
injuries  which  he  received.  From  these  injuries,  indeed,  he  had 
recovered,  as  soon  as  if  they  had  been  inflicted  in  any  other 
accident  and  in  any  other  way.  The  cause  of  his  illness  and  of 
his  altered  condition,  even  after  the  lapse  of  several  years,  was 
the  mental  shock,  call  it  fright  or  what  we  may,  which  the  whole 
circumstances  of  the  accident  wrought  upon  him.  There  is  no 
reason,  in  such  a  case,  to  believe  that  the  condition  is  due  to  any 
gross  pathological  change,  such  as  the  unaided  eye  might  see  upon 
the  post-mortem  table,  and  certainly  there  is  not  meningo-myelitis 
of  the  brain  and  spinal  cord. 

Evidences  of  the  immediate  effects  of  fright  alone  are,  of  course, 
not  often  obtainable.  In  the  following  case,  however,  it  was  re- 
corded in  the  official  report  of  the  accident  that  "  a  man,  name 
unknown,  was  so  frightened,  and  trembled  so  bad,  that  he  had 
to  be  detained  all  night." 

Case  ii. — General  nervous  shock — Great  fri'jht. — B.  J.,  aged 
forty-four,  a  thick-set,  somewhat  robust-looking  man,  was  in  a 
carriage  which  ran  off  the  line  when  the  train  had  just  left  a 
station,  and  which,  after  jolting  along  off  the  rails  for  a  few  yards, 
was  turned  over  on  its  side.  He  says  he  was  far  more  shaken, 
"terribly  shaken"  was  his  phrase,  by  the  previous  jolting  than 
by  the  overthrowing  of  the  carriage  ;  and  when  he  had  got  out, 
his  condition  was  that  mentioned  in  the  official  report.  On 
the  following  day  he  travelled  home  alone,  presenting  on  arrival 
so  dazed  an  appearance  that  his  doctor  was  immediately  sent  for. 
Ten  days  afterwards  he  was  suffering  from  muscular  pains,  in- 
creased by  movement,  in  various  parts  of  the  body,  and  due,  no 
doubt,  either  to  bruising  or  straining  when  the  carriage  had  been 
jolted  and  overturned.  "  He  can  hardly  get  any  sleep,  having 
before  his  mind  a  constant  fear  of  the  railway  accident,  and  he 
becomes  occasionally  '  light-headed '  at  night.  He  is  lying  in 
bed  with  his  eyes  closed  and  the  blinds  down,  complaining  that 
he  dreads  the  light.  He  gets  very  low-spirited,  and  frets  about 
his  business,  the  thought  of  which  pains  his  head.  He  is  much 
alarmed  at  the  pains  which  he  suffers,  says  he  is  afraid  to  move 
on  account  of  them,  and  that  he   fears  he   has  received  internal 

c 


i^ 


34  IIAILWAY    INJURIES. 

injury.  The  bowels  are  confined.  His  temperature  is  99''  F., 
and  bis  pulse  is  102."  Notwithstanding  his  expressions  of  fear, 
lie  was  able  to  sit  up  in  bed  without  sign  of  suffering,  and  in 
talking  he  moved  his  head  naturally  from  side  to  side.  He  very 
soon  also  seemed  quite  content  to  have  the  blind  drawn  up,  and 
gradually  opened  his  eyes.  There  was  no  evidence  of  liis  having 
received  any  bodily  injury  other  than  muscular  bruising  and 
strain,  and  his  condition  was  regarded  by  all  who  saw  him 
as  essentially  one  of  general  nervous  shock  likely  to  pass  away 
after  a  time.  When  seen  again  at  the  end  of  two  months,  he 
had  a  somewhat  worn  and  anxious  expression,  but  said  he  was 
better,  his  "nervousness"  being  not  so  great  as  it  was.  "He 
complains  of  being  easily  upset  and  startled,  and  that  the 
least  excitement  brings  on  a  sharp  pain  in  the  head.  The 
muscular  pains  are  better,  that  which  still  troubles  him  most 
being  a  pain  in  the  muscles  of  the  left  side  of  the  neck.  He 
sleeps  better,  though  he  occasionally  has  disturbed  nights.  He 
could  walk  two  or  three  miles  perhaps,  but  would  be  very  fatigued. 
His  pulse  is  100."  He  had  evidently  much  improved,  and  it 
was  advised  that  after  further  change  he  should  begin  his  work. 
Several  weeks  more  elapsed,  and  I  then  found  him  neither  looking 
nor  feeling  as  well  as  before.  He  was  very  nervous  about  him- 
self, felt  unable  to  do  his  work,  was  depi'essed  and  melancholy, 
and  losing  heart  from  the  thought  that  he  would  never  get  well. 
He  had  been  attending  to  his  business  for  two  or  three  hours  a 
day,  and  the  anxieties  of  it  were  very  distressing  to  him.  He 
was,  moreover,  very  anxious  to  arrange  his  pecuniary  claim  for 
compensation,  as  both  he  and  his  doctors  felt  that  that  was  now 
beginning  to  pi'ey  upon  his  mind.  In  bodily  health  he  seemed 
well.  Eighteen  months  after  his  claim  was  settled,  I  again  had 
the  opportunity  of  seeing  him.  He  was  then  in  perfect  bodily 
health,  able  to  follow  his  occupation  as  usual,  and  to  endure  as 
much  phj'sical  exertion  without  fatigue  as  before  the  accident. 
He  could  not,  however,  remain  as  long  at  his  desk  without  feeling 
worried,  and  his  wife  said  that  he  was  more  irritable  than  he 
used  to  be.  In  these  respects,  nevertheless,  he  was  admittedly 
improving,  and  he  himself  felt  confident  that  before  long  he 
would  be  absolutely  well. 

Case  i  2. — Slight  general  nervous  shock. — A  case  of  lesser 
severity  is  the  following : — M.  F.,  aged  forty- four,  a  man,  to 
use  his  own  expression,  of  "  excitable  temperament,"  was  in 
a  sharp  collision  which   the  whistling  of  the   engine  had  warned 


GENERAL  NERVOUS  SHOCK.  3  5 

him  was  going  to  happen.  He  had  thus  been  able  to  prepare 
himself  for  the  crash.  He  was  conscious  of  having  a  blow 
on  the  back  of  the  neck.  He  did  not,  however,  think  that 
he  had  been  hurt,  and  was  able  at  once  to  help  the  other 
passengers.  This  work  over,  he  walked  a  mile  to  catch  a  train 
at  another  station,  finished  his  journey,  and  completed  the  busi- 
ness which  had  called  him  away  from  home.  On  the  following 
day  he  felt  "  queer,"  and  sent  for  his  doctor,  who  found  hira 
agitated  and  depressed,  unable  to  occupy  himself,  and  complain- 
ing that  he  felt  shaken.  His  pulse  was,  however,  natural,  and 
his  temperature  normal.  He  subsequently  suffered  from  sleep- 
lessness, and  he  had  pains  in  various  parts  of  the  spinal  column, 
where  it  was  supposed  he  had  been  sprained  or  bruised.  There 
was  never  anv  evident  disturbance  of  the  organic  functions,  but 
for  some  months  he  suffered  from  sleeplessness,  from  much  depres- 
sion of  mind,  from  inability  to  occupy  himself,  and  from  a  con- 
stant sense  of  weariness  in  the  small  of  the  back.  After  change 
of  air  he  found  himself  better,  and  then  complaining  that  want 
of  work  was  distressing  to  him,  he  attempted  to  resume  his 
business,  but  found  that  it  made  him  worse,  more  nervous  and 
depressed,  and  more  sleepless  at  night.  Further  change  of  air, 
however,  did  him  good,  and  in  nine  months  he  arranged  his 
claim.  In  twelve  months  he  was  again  at  his  ordinary  work, 
having  "  entirely  recovered  "  from  his  illness.  He  continued  at 
his  business  for  some  years  afterwards,  and  then  retired. 

Case  13. — Neurasthenia  induced  hy  frigid. — Previous  ancemia. 
— A  lady,  aged  twenty-four,  was  in  a  collision  which  took  place  at 
night  without  the  slightest  warning.  The  luggage  fell  all  about 
the  carriage,  and  her  husband  was  thrown  against  her,  but  she 
herself  was  neither  moved  from  her  seat  nor  injured  on  any 
single  part.  As  soon  as  she  got  out  she  was  much  alarmed  at 
seeing  a  carriage  had  been  smashed  to  pieces,  and  then  she 
watched  a  man  being  rescued  from  the  debris  in  which  he  was 
buried.  She  went  on  her  journey,  and  the  next  day  felt,  to  use 
her  own  words,  as  if  she  had  passed  through  something  terrible, 
and  from  that  time  onwards  she  became  sleepless,  lost  her  appetite 
and  strength,  suffered  from  pain  in  the  back  of  her  head  and 
at  several  spots  down  her  spine,  and  was  quite  upset  by  any 
attempts  at  household  work,  or  by  reading  and  writing.  Think- 
insr  she  had  not  been  hurt,  her  friends  ursred  her  to  do  as  much 
as  possible  and  not  to  give  way,  but  she  steadily  got  worse 
rather  than  better,  and  although  not  in  the  least  hysterical,  it  was 


36  RAILWAY    INJURIES. 

not  until  proper  treatment  was  begun  that  improvement  set  in. 
The  case  was  complicated  by  previous  dysmenorrhcea  and  anaemia, 
both  of  which  were  increased  for  a  time  by  the  accident. 

Neuras-  5.   These  examples  give  a  good  idea  of  the  history  and  class  of 

ferentfrom  symptoms  which  cases  of  general  nervous  shock  usually  present, 
hysteria,     They  Were  all  of  them,  I  believe,  free  from  the  taint  of  conscious 

but  often  .  .  . 

associated  exaggeration  or  imposture,  but  it  must  be  abundantly  obviousi 
^^  ^ '  how  largely  the  reality  of  many  of  the  symptoms,  lacking  al\\ 
vestige  of  objective  sign,  depends  upon  the  veracity  and  goodC 
faith  of  the  patients  themselves.  On  this  account  it  is  that  j 
the  cases  are  so  difficult  to  describe,  and  that  it  is  almost  impos- 
sible to  convey  an  adequate  impression  of  them  to  those  who  may 
have  never  seen  them.  I  propose,  therefore,  to  bring  together 
and  to  say  something  about  each  of  the  various  symptoms  which 
are  commonly  met  with,  or  of  which  the  patients  complain,  when 
suffering  from  "  general  nervous  shock."  And  here  it  may  be 
well  to  premise  that  I  draw  a  broad  distinction  between  the 
condition  to  which  this  name  is  given  and  that  in  which 
genuine  hysteria  is  a  pronounced  symptom.  General  nervous 
shock  is  not  hysteria.  It  is  frequently  met  with  in  those 
who  show  no  hysterical  disturbance  whatever,  as  likewise  there 
may  be  much  hysteria  without  any  symptoms  of  general  nervous 
shock. 


Thorburn's       6.   Nevertheless,  while  I  see  much  to   agree  with,  and  that  I 
tion!'  '^^'    cannot  improve  upon,  in  Mr.   Thorburn's  tentative  classification  ^ 
of  the  post-traumatic  functional  neuroses — 

"  I.   Acute  effects. 

(rt.)  General  nervous  depression — '  shock  '  or  '  collapse.' 
(b.)  A  more  localised  and  defined  disturbance  of  cerebral 
(cortical)  origin — 'acute  hysteria'  or  'hysterics.' 
2.    Chronic  after-effects. 

(a.)   General  nervous  depression — '  neurasthenia.' 
{h.)  A  more  localised  and  defined  disturbance  of  cerebral 
(cortical)  origin — '  chronic  hysteria  '  " — 

it  is  by  no  means  uncommon  in  my  experience  for  the  two  states 
— hysteria  and  neurasthenia — to  be  associated  together.  Both 
are  originated  by  the  same  cause,  but  the  symptoms  due  to  each 
can  usually  be  determined.  Should  there  be  any  tendency  to 
^  A  Contribution  to  the  Surgery  of  the  Spinal  Cord,  p.  l86.     Griffin  &  Co.     1889. 


GENERAL  NERVOUS  SHOCK.  37 

hysteria,  the  state  of  general  nervous  depression  is  clearly  one 
likely  to  develop  and  maintain  the  purely  hysterical  disorder,  and 
it  is  frequently  obvious  that  the  hysterical  disturbance  protracts 
the  symptoms  which  are  really  dependent  on  the  general  nervous 
exhaustion.  To  cure  the  one  is  very  often  the  best  and  only  means 
of  removing  the  other. 

Thorburn  writes  : — "  The  symptoms  of  neurasthenia  arise  from  a 
general  defect  in  the  nutrition  and  action  of  the  nervous  system. 
.  .  .  The  symptoms  follow  those  of  shock,  and  are  the  expression 
of  an  exhausted  nervous  system.  They  are  generally  transient, 
and  will  pass  away  under  conditions  and  a  line  of  treatment  which 
niay  be  briefly  described  as  '  tonic' "  ^  Neurasthenia — to  use  the 
word  now  commonly  given  to  the  aggregate  of  symptoms  of  an 
exhausted  nerv^ous  system — is,  in  my  own  experience,  very  much 
more  common  than  hysteria.  It  is  characterised  by  some  or  all, 
in  varying  proportion  and  degree,  of  the  symptoms  which  I  shall 
now  describe,  placing  them  merely  in  the  order  of  their  frequency, 
after  a  careful  survey  of  many  hundreds  of  cases  personally 
observed. 


7.  Sleeplessness. — The  physiological  value  of  sleep  is  unquestion-  Symptoms 
able,  whether  we  merely  look  on  it  as  the  time  for  rest,  or  as  an  in-  tracted 
dication  that  no  bodily  or  mental  disturbance  is  there  to  prevent  it.  "^'"^°"'' 
Inability  to  sleep,  wakefulness  during  the  whole  or  part  of  the  night,  Sleepiess- 
is  a  sign  of  considerable  import  in  estimating  the  amount  of  injury 
and  of  shock  which  the  nervous  system  has  sustained.  It  shows 
that  something  has  happened  to  break  the  most  regular  habit  of 
life,  and  to  interfere  with  the  healthy  equilibrium  and  function  of 
the  whole  nervous  system.  This  continued  sleeplessness  may  be 
a  source  of  the  greatest  possible  distress  to  the  patient.  He  goes 
to  bed  tired  and  worn,  and  ready  to  fall  asleep,  but  no  sooner  is 
bis  head  on  the  pillow  than  he  is  seized,  as  it  were,  with  an  un- 
natural and  dominant  wakefulness  which  positively  prevents  him 
from  closing  his  eyes.  Or  he  falls  asleep,  and  soon  wakes  again,  and 
has  to  pass  through  a  night  of  intense  wretchedness,  nervous  and 
alive  to  the  slightest  sound.  The  fui-niture  creaks  or  the  mouse 
gnaws.  Night  after  night  this  goes  on,  and  he  tells  you  that  if  he 
could  only  sleep  he  is  sure  he  would  be  well.  And  what  he  says 
is  very  true,  for  not  only  has  there  been  no  serious  shock  to  the 
nervous  system  of  the  man  who  can  sleep  comfortably  and  well 
after  a  railway  accident,  but  on  the  other  hand  also,  the  return 

1  Op.  cit.,  p.  185. 


144GnO 


38  RAILWAY    INJURIF.S. 

of  sleep,  after  it  lias  been  long  absent  or  disturbed,  is  a  very 
certain  sign  that  the  nervous  system  is  regaining  its  equilibrium 
and  tone.  It  must  not  be  forgotten,  however,  that  sleeplessness 
may  be  due  to  other  causes  than  the  original  nervous  shock,  and 
that  it  may  form  a  prominent  complaint  in  those  cases  where 
convalescence  is  being  prevented  or  retarded  by  circumstances  of 
which  I  shall  speak  at  a  future  page.  Its  value  is  thus  to  some 
extent  impaired  as  a  diagnostic  symptom  of  general  nervous  shock 
from  railway  collision,  unless  it  be  at  periods  not  remote  from 
the  time  of  accident;  and,  furthermore,  there  is  frecpently  no 
means  of  knowing  whether  sleeplessness  is  undoubtedly  present- 
for  the  reality  of  its  existence  may  have  no  other  basis  than 
the  uncorroborated  statement  of  the  patient  himself. 


Disturb-  8.  Disturbances  of  the  Circulation. — Disorders  of  the  circulation, 

the  di°-  whether  of  the  heart  itself,  or  of  more  peripheral  parts  of  the 
cuiation.  circulatory  system,  play  a  no  less  important  part  in  the  nervous 
derangement  than  inability  to  sleep,  and  are  very  commonly  to 
be  met  with  in  cases  of  general  nervous  shock.  It  has  been 
pointed  out  already  that  the  shock  originally  showed  itself  by 
some  degree  of  cai'diac  paresis,  by  smallness,  feebleness,  or  slow- 
ness of  the  heart-beat.  It  is  a  natural  consequence,  therefore, 
that  in  the  more  serious  cases  of  nervous  shock,  especially  where 
continued  mental  terror  and  emotion  tend  to  perpetuate  the 
nervous  disturbance,  derangements  of  the  circulation  should  be 
frequent  and  long-continued.  The  patients  complain  of  palpita- 
tion, and  palpitation  from  altogether  trifling  causes.  The  cardiac 
innervation  may  be  so  disturbed  as  to  induce  great  frequency  of 
the  pulse,  which  may  vary  from  lOO  to  150;  but  far  more  com- 
monly the  palpitation  is  occasional,  and  it  is  only  from  exciting 
causes  that  the  pulse-beat  is  increased.  It  is  important  to 
remember  this  in  the  examination  of  patients,  for  if  you  count 
the  pulse  only  at  the  beginning,  and  omit  to  count  it  at  the 
end  of  examination,  you  may  be  led  to  believe  that  the  cardiac 
disturbance  is  more  serious  than  in  reality  it  is ;  and  by  the 
opposite  error  you  may  fail  to  discover  any  cardiac  disturbance 
at  all.  A  perfectly  steady  pulse  throughout  the  whole  examina- 
tion tells  its  own  tale.  Nay,  the  rate,  the  character,  and  the  ex- 
citability of  the  pulse  form  an  almost  metrical  indication  of  the 
amount  of  disturbance  of  the  nervous  balance,  strength,  and  tone  ; 
and  the  pulse  is  often  the  only  sign  there  is  to  guide  us  to  a 
right  estimate  of  the  patient's  condition.      It  is  important,  how- 


GENERAL  NERVOUS  SHOCK.  39 

ever,  to  learn  as  far  as  possible  the  character  of  the  patient's 
circulation  before  the  accident,  and  the  existence  of  any  consti- 
tutional states  or  diseases,  of  which  gout  is  perhaps  the  most 
common,  which  may  give  rise  to  functional  cardiac  disorder. 

But  while  the  state  of  the  pulse  may  form  the  test  of  what 
we  may  call  the  grosser  circulatory  disturbances,  there  are  yet 
other  symptoms  which  are  by  no  means  uncommon.  The  whole 
vaso-motor  system  may  be  deranged ;  and  when  you  hear  the 
patient  complain  of  alternate  sensations  of  heat  and  cold,  or 
of  flushing  of  the  face  and  head,  or  when  you  find  that  at  one 
time  his  hands  and  feet  are  unnaturally  warm,  and  at  another 
unnaturally  cold,  there  are  evidences  of  disturbance  in  those 
peripheral  parts  of  the  circulatory  system  which  are  not  neces- 
sarily or  immediately  under  the  same  nervous  influence  or  control 
as  the  heart  itself.  The  functional  strength  of  the  vaso-motor 
system  has  been  weakened — it  has  lost  its  nervous  tone  or  healthy 
balance ;  and  the  loss  is  shown  by  the  symptoms  which  have 
been  named,  as  well  as  by  the  occasional  presence  of  well-marked 
taclie  ch'^ralc.  These  disorders  will  be  referred  to  again,  for 
they  seem  to  me  to  have  some  share  in  giving  rise  to  the  abnormal 
sensations  of  which  complaint  is  often  made,  and  whose  obscurity 
tends  to  cast  doubt  upon  the  liona  fides  of  the  man  who  feels  them, 
and  who  can  only  describe  them  as  they  seem  to  him.  With 
returning  health  and  nervous  tone  these  various  symptoms  dis- 
appear, although,  as  will  be  presently  shown,  they  are  liable 
to  be  maintained  by  those  influences  and  circumstances  which 
tend  to  retard  convalescence. 


9.  Headache. — Intimately  connected  with  the  foregoing  symp-  Headache, 
toms  is  the  complaint  of  headache,  rarely  amounting  to  actual 
pain,  unless  indeed  there  has  been  concussion  of  the  brain. 
"  Pain "  is  so  relative  a  term,  however,  that  it  is  difficult  to 
estimate  it  at  its  true  value,  depending  so  largely  as  it  does  upon 
the  idiosyncrasy  of  the  individual.  More  common  than  actual 
pain,  or  the  sensation  to  which  the  word  pain  would  be  applied,  is 
a  sense  of  weight  or  oppression.  This  feeling  of  heaviness  may  be 
at  any  part  of  the  head,  but  is  most  common  at  the  back  of  it,  over 
the  whole  occipital  region.  Occipital  oppression  or  pain  is,  indeed, 
the  headache  79«7'  excellence  of  neurasthenia.  It  may  be  always  pre- 
sent, or  be  brought  on  by  attempts  at  mental  occupation — by  read- 
ing, talking,  agitation,  or  want  of  quietude.  Alcohol  nearly  always 
increases   it.      These   sensations    are    doubtless    to    some    extent 


40  IIAILWAY    INJUltlKS. 

dependent  on  the  irregularities  of  circulation  wliicli  have  been 
named.  The  exciting  causes  of  palpitation,  or  of  alternate  sensa- 
tions of  heat  and  cold,  may  at  the  same  time  indirectly  give  rise 
to  morbid  feelings  of  weight  and  heaviness  in  the  head.  Hence, 
also,  have  origin  the  sensations  of  giddiness  and  swimming  in 
the  head  when  the  patient  suddenly  rises  from  the  recumbent 
posture,  sensations  not  uncommonly  experienced  by  those  who 
are  first  beginning  to  move  about  after  serious  and  weakening 
illness.  These  various  abnormal  sensations  are,  moreover,  largely 
due  to  the  sleeplessness  which  is  so  common,  and  which  invariably 
shows  itself  in  impaired  mental  powei-,  as  long  as  the  brain  is 
deprived  of  natural  rest.  Occupation  of  the  mind  very  early 
induces  brain  fatigue,  and  this  fatigue  is  revealed  to  the  patient 
by  pain  or  oppression  of  the  head  and  by  an  indefinable  sense  of 
worry.  And  as  long  as  the  general  prostration  leads  to  lessened 
bodily  activity,  derangements  of  digestion,  constipation,  and  the 
like,  tend  in  a  still  further  degree  to  make  headache  a  not  un- 
common complaint  of  those  who  are  suffering  from  general  ner- 
vous shock.  Bring  about  sleep  and  natural  rest,  improve  the 
cardiac  tone  by  restoration  of  the  general  health  and  strength, 
and  it  will  be  found  that  the  headaches  and  the  brain  fatigue  soon 
pass  away. 


General  10.   Neivousness. — Under  this  heading  must  be  placed  a  variety 

of  complaints  and  symptoms  which  are  very  indefinite  in  char- 
acter, and  which  often  have  no  more  substantial  basis  than  the 
statements  of  the  patients  themselves.  But  they  are  the  kinds  of  y 
complaints  which,  in  my  judgment,  display  the  alliance  between-/ 
the  state  of  general  nervous  depression  and  true  hysteria.  Not 
that  this  association  is  always  to  be  found  or  is  always  obvious  in 
cases  of  hysteria,  but  that  in  this  particular  series  the  one  is  very 
much  dependent  on  the  other,  owning  a  common  cause,  and 
possibly  due  to  the  same  underlying  condition  of  the  nervous 
system.  Complaints  of  being  easily  startled,  of  a  sense  of  depres- 
sion and  melancholy,  of  trembling  under  excitement,  of  a  desire 
to  be  alone  and  to  avoid  all  noise,  of  hopelessness  as  to  future 
prospects  and  the  possibility  of  recovery,  of  agitation  in  the 
presence  of  others,  of  globus  hystericus — these  are  often  heard, 
and  their  nature  is  sufficiently  obvious  ;  and  beside  them  may  be 
placed  in  the  same  category  sighing  and  panting,  screaming  at 
night,  irritability  of  temper,  stuttering  and  stammering,  feeble- 
ness of  voice,   and   the   other   hundred   and  one  complaints  and 


nervous 
ness. 


GENERAL  NERVOUS  SHOCK.  4 1 

symptoms  wliich  may  be  taken  as  evidence  of  nervous  prostration 
and  loss  of  tone,  of  the  patient  having  been  reduced  to  a  more 
or  less  emotional  or  hysterical  state,  wherein  loss  of  control  is  a 
prominent  feature,  whether  it  be  as  cause  or  effect,  of  the  strange 
condition  in  which  the  patient  seems. 


11.  Disorders  of  Secretion  occupy  no  small  place  in  the  clinical  Sweating, 
picture  of  cases  of  general  nervous  shock.  Excessive  sweating  is  menor-^' 
one  of  the  most  common,  and  is  an  obiective  sign  of  wrong:  some-  j^^^'i!' 

,        ,         "^  ^  ^  diarrhoea. 

wliat  less  vague  than  the  subjective  symptoms  last  referred  to. 
It  is  an  evidence  of  impaired  nerve  function,  and  is  a  symptom, 
when  it  occurs  without  obvious  exciting  cause,  of  general  weak- 
ness and  prostration,  and  of  disordered  and  weakened  function 
of  the  nerves  which  control  the  action  of  the  sweat-glands. 

Here  also,  in  all  probability,  we   should  rightly  include  those 
vaso-motor  distui'bances  which,  limited  to  special  regions  or  tracts, 
may  also  give  rise  to  very  obvious  symptoms.      Of  these  Polyuria 
is  the   most  pronounced,  and  may  be  the  starting-point  of  much 
future  trouble  with  the  bladder,  for  the  frequency  of  micturition 
which  it  necessitates  may  continue  as  a  nervous  affection  long  after 
the  original  cause  for  it  has  been  removed.      Menorrliagia  is  also 
not  uncommon,  coming  on  within  a   few  hours   of  the  accident, 
and  wholly  independent  of  any  normal  menstrual  period  ;   and  in 
several  cases  profuse  Diarrhcea  has  begun  almost  immediately  after 
a  railway  collision.     These  also  must  be  regarded  as  kindred  signs 
of  vaso-motor  disturbance,  dependent,  in  all  probability,  on  some 
exhaustion  or  paresis  of  the  vaso-motor  centre — if  there  be  but 
one — in  the  upper  part  of  the  spinal  cord,  or  of  the  vaso-motor 
centres — if  there  be  many — in  different  parts  of  the  cerebro-spinal 
system.      How  strange  and  inexplicable  the  symptoms  may  some-> 
times  be,  was  well  shown  by  the  case  of  a  woman  who  was  terribly  \ 
frightened  by  the  thought  that  an  accident  was  going  to  happen*^ 
to  her  child,  and  who  was  herself  knocked  down  on  the  platform  atS 
a  railway  station.     She  had  had  polyuria  some  years  before,  and  it( 
now  came  on  again  soon  after  this  accident.      It  lasted  for  several  5 
weeks,  with  one  exception  of  twenty-four  hours,  during  which  it  / 
was  replaced  by  an  enormous  flow  of  milk  from  the  breasts.     SheyJ 
was  not  at  the  time  suckling.     Cases  such  as  this  seem  to  support  ( 
experimental  observation  as  to  the  presence  of  vaso-motor  centres 
in  the  cerebral  hemispheres,  and  better  to  explain  the  intimate 
association  of  emotional  and  vaso-motor  disturbances  than  if  the 
centres  lay  in  the  spinal  cord  alone. 


42  RAILWAY    INJURIES. 

Defects  of  12.  PhotophoMa,  Asthenopia,  and  Size  of  the  Pupil. — In  some  of 
Iheoi^ihi  the  worst  cases  of  general  nervous  shock  we  may  occasionally 
pupil.  meet  with  a  considerable  degree  of  photophobia.  This  is  usually 
a  transient  symptom  in  the  days  soon  after  the  accident,  and  is 
merely  an  evidence  of  the  severity  of  the  shock  and  of  the  need 
for  absolute  quiet.  The  patient  finds  a  strong  light  unbearable, 
just  as  he  cannot  bear  any  loud  noise.  Far  more  common  is 
the  subsequent  complaint  of  defect  of  vision,  even  when  there 
has  been  no  damage  to  or  near  the  eyeball.  "  I  can  read  for  a 
short  time,  and  then  the  lines  all  seem  to  run  together,"  the 
patient  tells  you  ;  and  he  thus  describes  a  symptom,  like  those 
which  have  gone  before,  of  prostrate  nerve  force.  The  asthenopia 
is  due  in  nearly  all  cases — whether  there  has  previously  been 
ametropia  or  not — to  loss  of  accommodative  power,  a  result 
of  the  general  weakness  and  depression  which  render  any  sus- 
tained effort  difficult  or  impossible.  It  is  merely  another  sign 
of  easily  induced  fatigue ;  and  in  those  persons  who  have  neither 
error  of  refraction  nor  presbyopia,  the  asthenopia  will  disappear — 
as  the  general  muscular  fatigue  and  the  brain  fatigue  will  dis- 
appear— with  returning  health  and  strength.  The  asthenopia  is 
precisely  the  same  as  that  which  is  a  not  uncommon  symptom  of 
hypermetropia,  and  which  may  be  felt  for  the  first  time  after  an 
exhausting  illness  or  during  the  weakness  induced  by  prolonged 
lactation.  In  vigorous  health  the  accommodative  power  is  adequate 
to  overcome  refractive  error  and  to  prevent  fatigue  of  vision  ; 
reduce  the  strength,  and  asthenopia  ensues  as  a  direct  conse- 
quence of  weakened  power  of  accommodation.  It  is  very  doubt- 
ful whether  this  power  will  ever  be  perfectly  restored  to  its 
orio-inal  strength  in  those  who  have  abnormal  refraction,  or  in 
whom  presbyopia  is  either  imminent  or  advanced.  Thus  you  find 
it  occasionally  happen  that  persons,  who  have  suffered  from  the 
shock  of  a  railway  collision,  must  in  future  years  wear  glasses  to 
correct  the  refractive  error  of  which  they  had  not  been  conscious 
before.  It  is  in  these  cases  of  induced  asthenopia  that  muscse 
volitantes  are  so  commonly  seen,  and  so  often  alarm  the  patient. 
They  are  of  no  pathological  significance  whatever,  and  as  a  matter 
of  fact  there  are  singularly  few  persons  to  whom  they  are  not  at 
times  apparent. 

The  size  of  the  j^W^^  often  affords  valuable  evidence  of  the 
state  of  the  nervous  tone.  A  widely  dilated,  sluggish  pupil  is 
incompatible  with  a  healthy  tone  of  the  nervous  system,  as, 
conversely,  a  small  pupil,  which  readily  varies  according  to  the 
degree  of  light,  is   a  rare   accompaniment  of  exhausted  nervous 


GENERAL  NERVOUS  SHOCK.  43 

strength.  Whatever  be  the  physiological  explanation  of  these 
facts,  the  size  and  activity  of  the  pupil  should  always  be  taken 
into  account  in  endeavouring  to  estimate  the  amount  of  general 
nervous  prostration. 


13.  The  Optic  Discs. — At  this  point  it  may  be  well  to  consider  The  optic 
whether,  in  addition  to  these  various  ocular  phenomena,  there 
is  a  risk  of  any  more  definite  pathological  change  arising  in  the 
deeper  structures  of  the  eye.  In  my  former  work  I  entered  at 
some  length  into  this  question,  and  the  conclusion,  drawn  from 
my  own  observations  and  the  records  of  published  cases,  amounted 
practically  to  this,  that  there  was  no  evidence  of  pathological 
change  being  common  in  the  cases  of  spinal  injury  and  general 
nervous  shock,  such  as  are  seen  after  railway  collisions.  I  had 
often  heard  the  retina  described  as  congested — whatever  that 
expression  might  mean — but  I  felt  sure  that  too  little  account 
had  been  taken  of  the  innumerable  varieties  of  shade  and 
colour  presented  by  the  normal  fundus  in  perfect  health,  and 
still  more,  I  will  now  add,  of  the  appearances  produced  in 
healthy  discs  when  refractive  errors,  hypermetropic  astigmatism, 
and  the  like,  had  not  been  taken  into  proper  account  in  ophthal- 
moscopic examinations.  I  emphasise  these  conclusions  now, 
not  alone  because  further  experience  supports  them,  but  also 
because  the  matter  has  been  more  recently  and  very  fully  in- 
vestigated anew  by  Mr.  Thorburn,  to  whose  work  the  reader 
must  refer.  He  is  iu  substantial  agreement  with  what  has  been 
said  here.  Thus  he  writes: — "Slight  sjoinal  injuries  are  very 
common,  but  there  is  no  evidence  that  they  tend  to  be  followed 
by  changes  in  the  optic  disc.  Such  injuries  are,  however,  in 
rare  cases "  (he  himself  having  met  with  two  only  in  400) 
"  followed  by  chronic  meningitis  or  myelitis,  and  in  the  latter 
condition  there  is  an  a  'priori  probability  that  optic  neuritis 
may  supervene.  Both  of  these  affections  ai"e,  however,  very  rare, 
and  with  the  exception  of  Dr.  Clifford  Allbutt's  eight  cases,  in 
which  we  have  not  the  material  for  an  accurate  diagnosis,  there  is 
but  one  recorded  instance  of  this  conjunction."^  Furthermore, 
speaking  of  the  traumatic  neuroses,  he  says — "  Here  changes  of  the 
optic  disc  are  so  rare  that  among  the  numerous  railway  injuries 
which  have  come  under  my  own  observation,  and  which  include 
many  severe  cases  of  traumatic  neurosis,  I  have  seen  but  one  doubt- 
ful case  of  lesion  of  the  optic  disc."      In  no  instance  has  he  seen 

'  Op.  cit.,  p    178. 


44  RAILWAY    INJURIES. 

the  functional  eye  symptoms  followed  or  accompanied  by  organic 
changes,  although  examination  of  a  few  recorded  cases  makes  it 
"  appear  that  there  is  an  a  priori  probability  that  the  functional 
traumatic  neuroses  may  give  rise  to  changes  in  the  optic  discSc" 
These  changes  are  indicated  by  transient  vascular  disturbance. 

The  sufferer  from  spinal  sprain  and  its  frequent  accompaniment, 
nervous  prostration,  has  therefore  small  cause  for  anxiety  on  this 
point ;  while  at  the  same  time  every  care  must  be  taken  that 
any  pathological  changes  discovered  are  not  the  result,  to  use 
Dr.  Gowers'  words  in  writing  of  this  very  class  of  cases,  "  of 
an  affection  of  the  mind  of  the  observer,  rather  than  of  the  eye 
observed."' 


Loss  of  14.  Loss  of  Memory. — Complaint  of  "  loss  of  memory  "  is  common, 

so^caUed.  ^^d  vet  the  phrase  is  hardly  an  appropriate  one  to  convey  an  accu- 
rate description  of  that  which  the  patients  usually  mean  by  it.  This 
so-called  loss  of  memory  is  not  an  inability  to  recall  the  events 
and  incidents  of  past  life,  but  is  rather  an  incapacity  for  sustained 
thought,  and  for  continued  application  to  the  work  which  may  be 
taken  in  hand.  It  is  a  lack  of  the  power  of  volitional  atten- 
tion, and  is  an  indication  of  easily  induced  fatigue.  It  is  not  a 
symptom  of  serious  import,  nor  is  it  evidence  of  mischief  in  the 
brain.  The  nutrition  of  the  brain,  as  of  the  rest  of  the  body, 
is  for  the  time  impaired,  and  there  is  failure  in  the  power  of 
concentration  and  attention.  It  is  merely  another  phase  of  the 
general  weakness,  and  of  the  inability  to  apply  himself  to  any 
settled  occupation,  which  a  patient  very  naturally  feels  under  the 
sense  of  w^eakness  and  depression  incidental  to  the  nervous  state 
in  which  he  is.  That  this  is  the  true  explanation  is  frequently 
shown  by  those  who  make  the  most  complaint.  They  can  relate 
every  incident  of  the  accident,  and  of  the  events  which  followed 
it,  and  they  are  perfectly  accurate  as  to  the  dates  of  many  occur- 
rences in  their  lives  both  before  and  since,  but  they  are  unable 
to  apply  themselves  to  work,  or  to  collect  their  thoughts,  or  even 
to  engage  in  conversation. 


Catameniai       15.   Catamenial  Derangements. — Menorrhagia  has  been   already 

nlentTand  named  as  a  not  uncommon  and  immediate  consequence  of  the  ner- 

preguancy.  ^^^^g  shock.     Suppression  of  the  catamenia,  either  at  the  moment 

of  the  accident,  or  as  a  subsequent  concomitant  of  the  general 

'  Medical  Ophtlialmoscopy,  2nd  ed.,  p.  1 69. 


GENERAL  NERVOUS  SHOCK.  45 

nervous  prostration,  is  likewise  not  unfrequent.  Who  shall  say 
what  determines  the  one  or  the  other  ?  The  catamenia  may 
thus  be  suppressed  for  several  months — in  fact,  until  the  neuras- 
thenical  condition  has  passed  away.  At  any  rate  the  return  of  the 
periodic  flow  is  usually  coincident  with  a  marked  improvement 
in  the  general  condition.  As  to  pregnancy,  this  may  be  pointed 
out  as  a  remarkable  fact,  that  railway  collisions  rarely  produce 
abortion  or  premature  labour — strong  evidence  that  the  concus- 
sion is  not  as  violent  as  it  is  often  thought  to  be,  for  disturbance 
of  the  uterine  contents  is  one  of  the  recognised  causes  of  induced 
labour.  But  although  the  fear  of  miscarriage  need  hardly  be 
entertained,  it  is  only  natural  that  the  injured  woman  should  feel 
more  than  ordinary  anxiety  as  to  the  coming  labour.  As  a 
matter  of  fact,  the  neurasthenia  keeps  this  anxiety  alive,  while 
the  anxiety  in  its  turn  keeps  up,  or  even  in  the  circumstances 
develops,  the  neurasthenia.  Suffice  it  that  it  is  very  unusual 
for  any  marked  improvement  to  be  noted  until  after  the  confine- 
ment. Then  follows  the  natural  result,  from  joy  that  a  man  is 
born  into  the  world. 


16.  The  Genito-Urinary  System. — Every  one  is,  of  course,  familiar  Thegenito- 
with  the  risks  of  retention  of  urine  in  all  cases  of  profound  shock,  ^ystenf 
and  this  should  never  be  lost  sight  of  in  the  case  of  persons 
injured  in  railway  collisions.  Unrelieved  hyperdistension  of  the 
bladder  may  be  the  cause  of  much  subsequent  trouble  from  the 
atony  thus  induced.  The  general  muscular  feebleness,  which  is 
a  marked  feature  of  the  state  of  neurasthenia,  may  also  in  both 
sexes  be  a  further  reason  why  the  bladder  is  not  completely 
emptied  in  micturition  ;  and  if,  as  has  already  been  remarked,  to 
these  causes  be  added  an  inability  to  get  out  of  bed,  there  is 
almost  certain  to  be  some  residual  urine — the  commonest  and 
most  generally  acknowledged  cause  of  cystitis. 

As  to  sexual  matters,  this  only  need  here  be  said,  that,  as  long  as 
the  neurasthenia  lasts,  there  is  not  likely  to  be  either  the  desire 
or  the  will.  Both  will  return  in  due  time,  but  before  that  time 
neither  should  be  gratified,  for  the  smallest  degree  of  sexual 
exhaustion  is  sure  to  be  most  prejudicial  to  recovery.  Conjugal 
isolation  should  be  rigidly  enforced  as  a  matter  of  treatment. 


17.   The  Digestive  System  is   ordinarily  much  deranged.      The. 
nausea,    and    even   the    vomiting,    which   have   accompanied   the 


46  RAILWAY    INJURIES. 

Disorders  early  collapsc,  are  botli  prone  to  continue,  and  the  patient  acquires 
tion  and  an  absolute  loathing  for  food.  The  bowels  are  costive  from  the 
nu  11  ion.  (.QjigQejjjgj^t  to  bed  or  the  house,  and  the  tongue  becomes  thickly 
lurred.  All  tliis  is  obviously  most  hurtful  to  the  neurasthenical 
state,  and  it  has  a  large  share  in  producing  the  wasting  and 
muscular  flabbiness  which  are  soon  developed.  The  wasting, 
however,  is  not  due  to  this  alone.  The  general  nutrition  is 
interfered  with  because  of  the  nervous  depression,  whereby  the 
proper  and  requisite  nervous  stimulus  is  withdrawn  from  the 
digestive  and  nutritive  processes.  Admittedly  this  is  theory 
only,  but  there  can  hardly  be  much  question  that  the  health  and 
vigour  of  the  nervous  system  are  essential  for  the  orderly  working 
of  every  other  function  in  the  body,  and  the  action  of  the  nervous 
system  in  connection  with  the  functions  of  nutrition  and  diges- 
tion is  not  more,  nor  is  it  less,  incomprehensible  than  is  its  action 
in  connection  with  the  circulatory  or  reproductive  systems.  At 
any  rate,  marked  general  wasting  is  often  a  striking  phenomenon 
in  cases  of  neurasthenia,  and  impaired  nutrition  may  frequently 
be  the  cause  of  bad  sleep. 


Prognosis  18.  Prognosis — Exceptions  to  the  usual  rule. — There  have  thus 
tions^tothe  been  brought  together  a  number  of  the  symptoms  and  complaints 
usual  rule,  -^yiiig]^  make  up  the  condition  to  which  the  term  "  neurasthenia  " 
is  nowadays  commonly  applied.  It  is  synonymous  with  that  of 
"  general  nervous  shock,"  which  has  been  used  so  often  in  these 
pages  ;  and  though  there  are  many  objections  to  it,  it  is  on  the 
whole  a  convenient  clinical  phrase.  It  has  at  any  rate  no  under- 
lying suggestion  as  to  the  pathology  of  the  condition  which  it  is 
meant  to  indicate.  Of  the  pathology  of  the  varied  complex  of 
symptoms  which  we  call  neurasthenia  nothing  indeed  is  known. 
We  say  there  is  general  depression  of  nervous  force,  a  dynamic  not 
a  structural  change,  resulting  for  a  time  in  the  manifestation  of 
one  or  all  of  the  symptoms  which  have  been  named.  For  a  time 
only  :  because,  however  severe  the  symptoms  may  be,  the  pro- 
gnosis of  these  cases  is  usually  favourable ;  and  with  appropriate 
treatment,  and  the  avoidance  of  all  things  likely  to  foster  the 
nervous  depression,  there  will  come  a  restoration  of  the  nervous 
strength  and  tone,  and  the  evidences  of  its  foi^mer  depression 
will  pass  away. 

This  is  the  ordinary  rule,  but  the  gravity  of  the  condition  is 
attested  by  occasional,  by  happily  very  rare,  instances,  in  which 
the  result  is   different.      The   history  of  nervous  shock  would  be 


GENrmAL  NERVOUS  SHOCK.  47 

incomplete  wore  110  mention  made  of  the  fact  that  death  some- 
times ensues  as  a  consequence  of  uncomplicated  nervous  exhaus- 
tion. No  case  of  this  kind  has  fallen  under  my  own  observation, 
but  the  following  examples  were  communicated  to  me  by  a 
surgeon  of  large  experience  in  railway  injuries,  the  only  cases, 
it  may  be  said,  which  he  had  met  with  in  a  period  of  more  than 
thirty  years. 

Case  14. — Severe  shocJc — Death  from  general  nervous  prostration. 
— A  man,  forty  years  of  age,  of  exceedingly  delicate  physique, 
was  in  a  collision  at  night.  The  accident  was  a  slight  one,  and 
he  was  the  only  passenger  injured.  He  was  said,  in  the  official 
report,  to  be  "  violently  shaken,"  but  he  was  able  to  go  on  home. 
The  next  day  he  was  delirious,  and  on  the  third  day  he  was  still 
talking  somewhat  incoherently.  He  complained  of  being  much 
shaken,  and  of  feeling  seriously  injured,  but  there  was  no  evidence 
discoverable  of  bodily  hurt.  He  improved  for  a  time,  and  his 
condition  was  not  thought  to  be  serious.  He  never  seemed,  how- 
ever, to  make  any  marked  progress,  and  four  weeks  after  the 
accident  he  became  more  prostrate,  and  greater  anxiety  was  felt 
about  him.  From  this  time  he  gradually  got  weaker  and  weaker, 
and  died  on  the  thirty-seventh  day.  No  organic  disease  whatever 
was  found  on  post-mortem  examination  in  any  of  the  viscera.  The 
lungs  were  greatly  congested,  and  the  cavities  of  the  heart  were 
distended  with  blood,  as  if  death  had  occurred  from  failure  of 
respiration  and  circulation. 

The  accident  was  regarded  as  the  unquestionable  cause  of  the 
death.  Though  moderate  in  character,  it  no  doubt  exercised  a 
very  unusual  influence  in  depressing  vital  powers — never  very 
strong  naturally — and  finally  induced  such  an  amount  of  nervous 
exhaustion  as  to  terminate  fatally,  even  though  there  were  no  evi- 
dences before  or  after  death  of  physical  injury  to  any  one  part. 

Case  15. — Severe  sliock  from  fright  ending  fatally. — The  other 
case  was  that  of  an  apparently  strong  and  healthy  girl,  nine- 
teen years  of  age,  in  good  position  in  life,  who  was  in  a  most 
serious  collision.  She  received  no  bodily  injury,  but  on  the 
night  of  the  accident  she  woke  screaming  that  the  engine  was 
rushing  into  the  room.  Her  illness  followed  much  the  same 
course,  and  she  died  in  about  five  weeks,  no  structural  disease 
whatever  being  found  after  death.  The  brain  and  spinal  cord 
were  examined  in  both  instances. 


48  RAILWAY    INJURIES. 

Cases  such  as  these  are  happily  most  rare.  They  are  not 
peculiar  to  railway  accidents,  and  similar  examples  of  death 
from  mental  shock,  without  any  organic  change  discoverable,  are 
recorded  in  works  on  nervous  diseases. 


The  com-  19.  The  Complex  of  Symptoms. — Taking  a  final  view  of  the 
symptoms,  symptouis  and  cases  recorded,  one  can  hardly  fail  to  see  how 
indubitably  all  of  them  point  to  a  state  of  lowered  nervous 
action  or  tone,  and  that  there  is  a  weakening  and  depression  of 
every  function  which  is  under  nerve  control.  In  other  words, 
the  function  of  every  organ  and  structure  in  the  body  is  affected. 
There  is  mental  weakness  and  there  is  physical  weakness ;  weak- 
ness of  will,  of  attention  and  power  of  thought ;  weakness,  or  easily 
induced  fatigue,  of  the  special  senses  which  minister,  both  con- 
sciously and  unconsciously,  to  the  processes  of  the  mind ;  feeble- 
ness of  voluntary  muscles  and  general  lack  of  muscular  tone  ; 
and  feebleness  of  the  involuntary,  as  shown  by  the  character  of 
the  circulation  both  central  and  peripheral,  by  want  of  tone  in 
the  bladder  wall,  and  by  feeble  peristalsis  in  the  intestines ; 
depression  of  the  secretory  apparatus  indicated  by  sweating  and 
other  vaso-motor  distui-bances ;  impaired  digestion  and  nutrition, 
and  loss  of  sexual  vigour — each  and  all  bear  witness  to  the 
nervous  exhaustion  and  depression,  to  the  widespread  weakness 
Avhich  results  from  the  nervous  shock,  and  is  expressed  in  the 
convenient  word  "neurasthenia." 


CHAPTER  III. 

GENERAL   NERVOUS   QJIOCK-{Co7itinued). 

Summary. — l.  Alliance  of  neurasthenia  and  hysteria. — 2.  "Hysteria "in  men. — 3. 
Protraction  of  symptoms  and  delayed  recovery.- — 4.  Combination  of  mental  and 
physical  states. — 5.  The  organic  sensations. — 6.  Fixed  attention,  anxious  reflec- 
tion, and  exaggeration. — 7.  Baneful  influence  of  litigation  and  causes  of  chronic 
invalidism. — 8.  Importance  of  the  previous  state  of  health  and  habits  of  life. — 
9.  Absence  of  prolonged  symptoms  in  cases  of  fracture.  — 10.  The  prospects  of 
the  future  health. 

1.  I  SHALL  now  consider  some  of  the  causes  which  contribute  Alliance  of 
to  prolong  the  symptoms  which  have  been  described  in  the  last  thenia  and 
chapter,  and  shall  endeavour  to  show  wherein  there  is  an  alliance  hysteria, 
between  the  state  of  neurasthenia  and  the  development  of  con- 
ditions which  are  more  distinctly  of  an  hysterical  type.  For 
although  on  paper  it  may  be  an  easy  thing,  and  for  purposes 
of  clear  understanding  a  useful  thing,  to  separate  the  different 
effects  of  railway  collision  into  distinct  classes,  I  yet  entertain  no 
doubt  that  neurasthenical  and  hysterical,  or  so-called  functional, 
disorders  of  the  nervous  system  are  closely  linked  together,  and 
are  very  often  to  be  found  side  by  side  in  the  clinical  picture 
presented  to  us.  They  have  a  common  exciting  cause,  and  both 
may  begin  at  the  moment  of  the  accident,  as  those  cases  show 
in  which  an  outburst  of  "  acute  hysteria,"  to  use  Mr.  Thorburn's 
phrase,  has  occurred  immediately.  More  commonly,  however, 
the  signs  of  hysteria  are  developed  at  a  later  period,  and  are 
developed,  I  believe,  through  and  by  the  intermediate  agency 
of  neurasthenia,  which,  as  it  were,  prepares  the  nervous  system, 
or  puts  it  into  a  suitable  state,  for  the  origination  of  true 
hysterical  disturbance.  The  profound  psychical  shock  of  a  rail- 
way collision  may  there  and  then  determine  some  grave  hysterical 
disorder  of  the  emotions  only,  or  of  some  more  definite  function, 
such  as  that  of  common  sensation ;  or  it  may  do  so  only  after 
there  has  been  sufiicient  time  for  the  nervous  system  to  reach 
that  condition  of  functional  weakness  in  which  hysterical  disturb- 
ances are  prone  to  arise.      Neurasthenia  is  that  condition  ;   and  a 

D 


50 


RAILWAY    INJURIES. 


very  common  sequence  of  events  is  fur  hysterical  disturbances  to  be 
grafted  on  to  the  neurastlienical  state — grafted  on  to  it,  and  there- 
after growing  with  it.  I  mean  no  more  than  this  when  I  say  that 
they  are  linked  together,  and  although  I  have  sought  to  convey 
the  impression  of  a  close  alliance  between  the  two  conditions 
and  their  respective  symptoms,  I  am  yet  in  substantial  agreement 
with  Mr.  Thorburn  in  his  opinion  "  that  neurasthenia  and  hysteria 
are  distinct,  and  that,  often  as  they  are  found  in  combination, 
neurasthenia  is  common  without  hysteria,  and  hysteria  is  at  least 
not  unknown  without  neurasthenic  symptoms."  ^ 


"Hysteria"  2.  Sex  plays  but  a  small  part  in  the  association,  and  although 
m  men.  ^^  ordinary  life  women  are  more  commonly  emotional  tlian  men, 
it  is  nevertheless  true,  that  as  the  direct  and  indirect  outcome 
of  the  nervous  shock  of  a  railway  collision,  men  may  become  no 
less  emotional  and  hysterical  than  women.  "  The  frequency  of 
hysteria  in  men  is  not  fully  recognised,"  Mr.  Furneaux  Jordan 
wrote  ^  some  years  ago  ;  but  we  all  know  now  that  a  condition 
closely  allied  to,  nay  identical  with,  the  hysteria  of  women,  is 
commonly  developed  in  men  after  the  great  psychical  shock  of 
a  railway  collision,  or  through  the  neurasthenia  induced  thereby. 
I  shall  waste  no  words  in  academic  discussion  as  to  the  use  of 
the  term  "  hysteria "  as  applied  to  men.  When  a  better  is  in- 
vented it  shall  be  used,  but  in  the  meantime  we  have  to  consider 
the  why  and  the  wherefore  of  the  distressing  condition  to  which  a 
strong  and  healthy  man  may  be  in  time  reduced — a  condition  in 
which  all  control  of  the  emotions  is  well  nigh  gone ;  in  which  he 
cannot  sleep  because  he  has  before  his  mind  an  ever-present  sense 
of  the  accident ;  starting  at  the  least  noise  ;  lying  in  bed  almost 
afraid  to  move  ;  his  heart  palpitating  whenever  he  is  spoken  to  ; 
and  unable  to  hear  or  say  a  word  about  his  present  condition  and 
his  future  prospects  without  bursting  into  tears. 


Protrac- 
tion of 
symptoms 
and 

delayed 
recovery. 


3.  The  longf  continuance  of  such  a  condition  forms  an  obvious 
exception  to  the  ordinary  rule — to  the  rule,  with  which  all  are 
familiar  in  everyday  practice,  that  convalescence  is  soon  entered 
upon,  and  that  the  symptoms  of  the  original  shock  become 
gradually  less  severe,  and  in  the  course  of  a  few  weeks  or 
months  glide  almost  imperceptibly  into  a  state  of  health,  so 
that  the  man  is  able  once  more  to  resume  his  business,  and  to 
1  Op.  cit.,  p.  189.  -  Ojh  cit.,  p.  27. 


GENERAL  NERVOUS  SHOCK.  5  I 

engage  in  the  pursuits  of  life.  Convalescence,  however,  may  be 
unduly  delayed  after  the  shock  of  a  railway  collision,  the  symptoms 
and  their  duration  seeming  to  be  out  of  all  proportion  to  the 
injury  sustained ;  or,  convalescence  having  once  set  in,  and  the 
patient  being  almost  well  enough  to  resume  his  work,  the 
symptoms  may  recur  in  all  their  severity,  and  the  period  of 
recovery  be  much  delayed.  What  are  the  reasons  which  conduce 
to  this  protraction  of  the  illness,  and  which  conduce  also  in  great 
measure  to  delay  in  convalescence,  when  all  the  circumstances, 
the  amount  of  injuiy,  and  the  evidences  of  initial  shock,  pointed 
in  the  direction  of  very  early  recovery  ? 


4.   Comparatively  little  has  been  said  hitherto  of  the  bodily  in-  Combina- 
juries  received,  and  it  has  been  assumed  throughout  that  the  causes  cental  and 
originally  at  work  to  bring  about  the  shock  and  its  after-conse-  pi^ysicai 
quences  were  essentially  psychical.     The  fact,  however,  must  never 
be  lost  sight  of,  that  there  are  few  cases  of  nervous  shock  after 
railway  collision,  in  which  sovie  bodily  injury  has  not  likewise  been 
sustained.     The  mode  of  accident,  as  we  have  already  seen,  has  a 
tendency  to  cause  injury  of  the  vertebral  column,  an  injury  which 
in  the  majority  of  cases  is  a  simple  sprain  of  the  spinal  muscles 
and  spinal  ligaments,  with  severe  vertebral  pain  as  an  inevitable 
consequence.      Sprains  are,  moreover,  not  unlikely  to  have  been   I 
received  in  other  parts  of  the  body,  even  when  the  patient  was  •^ 
perfectly  conscious  at  the  time  that  he  had  no  blow,  and  not  a 
mark  is  subsequently  to  be  seen.      Hence  it  comes  to  pass  that 
from  the  inherent  nature  of  the  bodily  injuries  themselves,  pain, 
in  various  parts  of  the  body — in  the  trunk  and  in  the  ai-ms  and 
legs — is  very  liable  to  come  on  some  time  after  the  accident,  to 
be  severe   in   character,  deep-seated    in    position,   and,  from  the 
absence   of   all    bruising,    seemingly   most    obscure.       Psychical 
causes  are  again  at  work  to  aggravate  the  patient's  condition. 
His  mental  balance  has  already  been  upset  by  the  shock  of  the  ! 
collision,  and  it  is  disturbed  still  further  by  the  onset,  the  char- 
acter,  and   the   obscurity   of  the   pains   which   supervene.     And 
this   result   is   most  likely  to    occur   in  those   cases   where   the 
appearance    of   the    pains   has    been  delayed    for  two   or   three 
days.      They  renew  the  alarm   of  the  injured  man,  his    atten- 
tion is  thereby  more  closely  directed  to  them,  and  their  import 
becomes  gravely  aggravated  in  his   mind.      These  pains,   more- 
over,   are   prone   to   increase    in    severity   during  the    first    few 
days,  and   to    last    for  a    long    time,   and   their  very   duration 


5  2  RAILWAY    INJURIES. 

tends  to  maintain  the  exaggerated  estimate  wliich  has  been 
formed  of  them  by  the  patient  himself.  Nor  does  familiarity 
with  them  lessen  his  alarm,  for  the  original  psychical  disturbance 
has  laid  the  sure  foundation  for  an  altogether  erroneous  estimate 
of  the  sensations  which  he  feels.  And  thus  you  find  that  before 
very  long  the  mind  of  the  patient,  unhinged  by  the  shock,  and 
directed  to  the  pains  and  other  abnormal  sensations  of  his  body, 
tends  as  it  were  to  run  riot  with  the  symptoms  which  he  feels. 
Dwelling  constantly  on  his  bodily  sensations,  he  is  on  the  look- 
out for  any  new  sensation  that  may  arise,  and  is  alive  to  and 
makes  discovery  of  sensations,  which  to  the  healthy  have  no 
existence  at  all.  Perhaps  he  even  keeps  a  chart  of  his  back  or 
of  his  whole  body,  and  marks  down  from  day  to  day  the  precise 
spots  where  he  has  had  some  queer  sensation,  ache,  or  pain. 


The  5.   Is  it  possible  that  a  large  number  of  the  abnormal  sensa- 

sensations.  tions  which  are  thus  discovered,  and  of  which  patients  so  fre- 
quently complain  while  the  mental  balance  and  tone  are  thus 
perturbed,  can  be  due  in  any  measure  to  a  conscious  perception 
of  the  sensations  of  organic  life  ?  The  "  hysterical "  condition 
is  essentially  one  in  which  there  is  loss  of  control  and  en- 
feeblement  of  the  power  of  the  will,  and  amidst  the  various 
ways  in  which  these  may  show  themselves,  there  is  loss  of 
the  habitual  power  to  suppress  and  keep  in  due  subjection 
the  sensations,  which  are  doubtless  associated  with  the  various 
functions  of  the  organic  life  of  the  individual.  In  the  pro- 
cess of  evolution  towards  a  higher  state  of  intellectual  activity 
and  endowment,  man  has  become  more  and  more  unconscious 
of  the  sensations,  which  of  necessity  accompany  the  functional 
activity  of  the  various  organs  and  structures  of  his  body. 
That  the  stomach,  for  example,  the  liver,  the  heart,  the  ovary, 
the  oesophagus,  are,  as  are  the  organs  of  special  sense,  repre- 
sented somewhere  and  somehow,  though  in  less  degree,  in  the 
sensorium,  is  highly  probable  on  a  priori  grounds,  and  is,  more- 
over, established  by  the  experiments  of  morbid  physiological  action, 
in  originating  those  abnormal  sensations,  which  may  affect  these 
and  other  parts  by  an  aura  at  the  commencement  of  an  epileptic 
discharge.  And  if  in  perfect  health  of  body  and  stability  of  mind 
these  varied  sensations  play  little  part  in  the  sentient  life  of  the 
individual,  it  is  because  the  intellectual  development  of  man  has 
enabled  him  to  control  them,  and  to  allow  them  neither  lot  nor 
share  in  the  sentient  consciousness  of  active  life.      In  the  lower 


GENERAL  NERVOUS  SHOCK.  53 

animal,  whose  brain  is  hardly  differentiated  from  the  other 
parts  of  its  nervous  system,  or  which  has  no  brain  at  all,  the 
organic  sensations  doubtless  have  a  more  important  part  in  the 
economy,  and  probably  in  the  enjoyment  of  life ;  but  as  we  step 
higher  and  higher  in  the  scale  of  development,  with  increasing 
size  and  complexity  of  brain,  the  organic  sensations  have  a  pro- 
portionately smaller  representation  in  the  centres  of  intellectual 
activity.  Let  some  sudden,  profound  psychical  disturbance  arise, 
such  as  may  be  induced  by  the  shock  and  terror  of  a  railway  collision, 
forthwith  the  intellectual  control  is  lessened,  while  the  organic  sen- 
sations declare  their  being,  and  force  themselves  into  the  conscious 
life  of  the  individual.  "  If  the  nervous  system,"  writes  Sully,  "  has 
been  slowly  built  up,  during  the  course  of  human  history,  into  its 
present  complex  form,  it  follows  that  those  nervous  structures  and 
connections  which  have  to  do  with  the  higher  intellectual  pro- 
cesses, or  which  represent  the  larger  and  more  general  relations  of 
our  experience,  have  been  most  recently  evolved.  Consequently, 
they  would  be  the  least  deeply  organised,  and  so  the  least  stable ; 
that  is  to  say,  the  most  liable  to  be  thrown  hors  de  comhat. 

"  This  is  what  happens  temporarily  in  the  case  of  the  sane, 
when  the  mind  is  held  fast  by  an  illusion.  And,  in  states  of 
insanity,  we  see  the  process  of  nervous  dissolution  beginning  with 
these  same  nervous  structures,  and  so  taking  the  reverse  order  of 
the  process  of  evolution.  And  thus,  we  may  say  that  throughout 
the  mental  life  of  the  most  sane  of  us,  these  higher  and  more 
delicately  balanced  structures  are  constantly  in  danger  of  being 
reduced  to  the  state  of  inefficiency,  which  in  its  full  manifestation 
is  mental  disease."  ^ 

And  thus  it  is,  it  seems  to  me,  that  when  by  the  profound 
shock  of  a  railway  collision  the  "  higher  intellectual  processes  '"'  are 
thrown  Jiors  de  comhat,  these  organic  sensations,  which,  as  the 
same  writer  says,  "  constitute  for  the  most  part  in  waking  life  an 
undiscriminated  mass  of  obscure  feeling,  of  which  we  are  only 
conscious  as  the  mental  tone  of  the  hour,"  and  which  form  "  '  as 
the  vital  sense '  an  obscure  background  for  our  clear  discrimina- 
tive consciousness,  and  only  come  forward  into  this  region  when 
very  exceptional  in  character,"  ^  step  out  of  their  natural  obscurity, 
and  become  the  foci  of  the  uncontrolled  and  misdirected  attention 
of  the  mind.^ 

^  Illusions,  p.  122. 
-  Ibid.,  pp.  148,  149. 

'  The  reader  will  find  some  interesting  and  philosophical  remarks  on  the  subject  in 
Dr,  Mercier's  able  work,  Sanity  and  Insanity,  pp.  85-94.     1S90. 


54 


RAILWAY    INJURIES. 


Not  one  of  the  abnormal  sensations  lias  any  organic  lesion  as 
its  basis,  but  that  there  is  some  physical  substratum  seems  higlily 
probable.  Continued  disorders  of  the  circulation  are  the  most 
obvious  after-signs  of  shock,  and  it  is  not  at  all  unlikely  that 
many  of  the  morbid  sensations  which  form  the  burthen  of  the 
patient's  complaints  have  a  real,  not  an  altogether  imaginary, 
basis  in  transient  flushing,  or  in  transient  anaemia,  of  the  affected 
part.  Some  such  cause  as  this  must  be  at  the  root  of  many  of 
the  sensations  which  afflict  peripheral  regions  of  the  cutaneous 
surface,  and  not  improbably  of  those  also  which  are  felt  in  the 
central  or  in  more  vital  parts. 


Fixed  6.   And  as  the  mental  state  may  be  influenced  and  deluded  by 

anx^us"^'    ^^^  abnormal  sensations,  so  in  an  even  greater  degree  may  these  be 
reflection,    affected  bv  the  mind.    The  results  of  attention,  of  anxious  attention 

and  exag-  "^  ,         ,     .  -,    p 

geration.  concentrated  on  a  part,  are  seen  m  their  most  aggravated  torms. 
Pain  and  other  morbid  sensations  are  thus  made  more  acute  and 
more  oppressive;  they  become  more  dominant  in  the  mind,  and 
less  under  the  control  of  the  already  weakened  will.  Small 
wonder  that  the  patient,  alive  to  every  new  sensation  which  may 
arise,  should  tend  to  exaggerate  its  import,  to  describe  it  in 
terms  which  to  the  healthy  man  seem  almost  absurd,  and  that 
exaggeration  should  be  a  pronounced  feature  of  the  morbid  state 
which  is  called  hysteria,  no  matter  which  be  the  sex  affected. 


Baneful 
influence  of 
litigation 
and  causes 
of  chronic 
invalidism. 


7.  And  out  of  this  very  exaggeration  itself  arises  another  cause 
of  prolongation  of  the  illness.  The  exaggerated  estimate  of  the 
symptoms  themselves  leads  to  an  erroneous  estimate  of  the  pre- 
sent incapacity,  and  to  an  increasing  belief  in  the  impossibility  of 
future  recovery  and  usefulness.  Hence  it  is  only  natural  that  differ- 
ences of  opinion  should  arise  between  those  who  are  entitled  to  re- 
ceive compensation  for  the  injuries  and  for  their  prospective  conse- 
quences, and  those  who  have  to  provide  it,  and  who  take  a  wholly 
unsentimental  view  of  the  value  of  the  patient's  health  and  life. 
Months  perhaps  are  thus  wasted  in  disputing  about  the  claim  ; 
or,  worse  than  this,  the  man  is  drawn  unwittingly  into  litigation, 
and  is  subjected  to  the  anxieties  and  worries  which  a  lawsuit 
involves.  What  suiter  means  than  this  for  aggravating  his  symp- 
toms ?  Is  recovery  possible  under  such  an  influence ;  is  there 
not,  indeed,  every  likelihood  that  the  symptoms  will  get  worse 
and  worse,  or  at  best  will  undergo  no  change,  and  is  it  not  more 


GENERAL  NERVOUS  SHOCK.  5  5 

appropriate  now  to  call  them  "  litigation  symptoms,"  than  those 
of  general  nervous  shock  ? 

And  herein  also  lies  the  explanation  of  the  great  majority  of 
those  cases  where  improvement  has  advanced  to  such  a  stage  that 
return  to  work  seems  on  all  hands  desirable,  and  yet  nevertheless 
when  work  is  suggested  or  attempted  improvement  stops ;  and 
even  in  some  instances  the  patient  seems  from  that  very  moment 
to  fall  back  and  to  become  worse  than  he  was  before.  For,  as 
a  matter  of  fact,  it  is  very  rare  to  find  the  patients  return  to  * 
work  while  the  question  of  compensation,  and  the  possible  dis- 
putes attending  it,  remain  unsettled.  Now  and  then  you  may 
meet  with  a  patient,  over  whose  plans  and  resolves  the  time  and 
matter  of  compensation  have  little  influence,  who  returns  to  his 
business  with  every  benefit  to  himself  at  the  moment  when  he 
has  sufficiently  recovered  to  do  so.  Such  instances,  however,  are 
the  exceptions  to  the  rule,  and  occur  probably  in  those  only  whose 
mental  balance  has  never  been  very  seriously  upset,  in  whom 
the  symptoms  of  general  nervous  shock  have  not  been  severe,  or 
who  have  the  good  judgment  not  to  allow  these  matters  to  weigh 
upon  their  minds.  The  experience  of  hosts  of  cases  establishes 
this  fact,  that  patients  will  not,  or  cannot,  make  the  necessary 
effort  to  resume  work  so  long  as  the  settlement  of  the  pecuniary 
claim  has  been  unefFected.  And  thus,  in  addition  to  the  worries 
and  anxieties  of  litigation  and  dispute,  there  arises  another 
very  potent  cause  for  continuance  of  the  symptoms,  and  for 
inducing  a  state  of  chronic  invalidism,  which  is  far  more  de- 
pendent upon  the  circumstances  of  the  moment  than  upon 
the  original  nervous  shock  received.  This  cause  is  the  want 
of  occupation.  Can  anything  be  worse  for  a  man — is  there 
anything  more  likely  to  lead  to  irritability  and  fretfulness,  to 
sleeplessness  and  loss  of  appetite,  to  nervousness  and  anxiety 
about  himself,  to  hopelessness  as  to  the  future,  to  a  lack  of  power 
to  concentrate  his  attention  upon  anything  which  he  may  have 
in  hand — is  there  anything  more  fitted  to  disturb  the  relation 
between  the  mens  sana  and  the  corpus  sanuiii  than  want  of 
healthy  occupation  ?  And  when  this  goes  on  for  months  and 
months,  each  month  more  wearisome  and  more  wasted  than  the 
one  before,  is  it  to  be  wondered  at  that  the  picture  which  these 
patients  present  is  often  lamentable  indeed  ?  Still  more  wretched 
is  it  likely  to  become  if,  in  addition  to  the  want  of  occupa- 
tion, the  patient  has  remained  altogether  indoors,  and  has  been 
deprived  of  the  good  which  healthy  bodily  exercise  might  have 
done  him. 


5  6  RAILWAY    INJURIES. 

Make  all  the  allowance  that  may  honestly  be  made  for  the 
special  circumstances  of  terror  attendant  upon  a  railway  col- 
lision— and  I  would  not  for  a  moment  seek  to  lessen  their  real 
influence — and  compare  the  state  of  one  waiting  for  compensa- 
tion, whom  for  the  nonce  we  will  call  a  railway  patient,  with  the 
state,  as  nearly  similar  as  may  be,  of  a  hospital  patient  who  has 
had  no  compensation  to  look  forward  to,  and  who  has  been 
compelled  to  resume  his  work  as  soon  as  he  was  able,  and  then 
see  how  different  is  their  lot,  and  how  infinitely  less  wretched 
is  the  one  man  than  the  other.  The  hospital  patient  has  long 
ago  been  well,  while  the  railway  patient  has  been  waiting,  for 
months  it  may  be,  until  compensation  has  been  paid  him,  verily 
believing  that  he  could  not  return  to  work  and  to  a  natural  and 
more  healthful  mode  of  life.  "  Settle  your  claim  and  get  to 
work,"  is  the  best  advice  which  can  be  given  a  man  in  these  cir- 
cumstances. Get  to  work  and  you  will  soon  find  you  have  the 
strength  for  it,  and  will  forget  the  gloomy  prognostications  of 
those  who  say  that  you  never  can  tell  what  may  happen  after  a 
railway  accident,  and  that  you  ought  to  wait  and  see  how  things 
turn  out. 


Import-  8.   Quite   apart,  however,   from  these  various  causes,  the  con- 

previous  ^^  dition,  life,  and  habits  of  the  patient  before  the  accident  have  no 
state  of  small  share  in  determining  the  severity  of  his  symptoms  and  the 
habits  of  rate  of  his  recovery  after  it.  It  is  evident  that  the  man  who  has 
been  in  feeble  health,  or  who  is  in  a  state  of  convalescence 
from  some  recent  illness,  is  likely  to  present  the  symptoms  of 
neurasthenia  in  an  extreme  degree  ;  as  also  does  the  man  who, 
although  in  perfect  health,  has  been  living  a  life  of  hard  and 
constant  work  at  the  high  pressure  which  everyday  competi- 
tion entails.  He  has  an  extensive  business,  with  numbers  of 
subordinates,  and  widespread  interests  in  connection  with  it, 
which  he  must  himself  look  after,  and  which  he  cannot  delegate 
to  another.  He  has  been  in  good  health,  but  this  has  been  his 
life,  and  he  has  had  no  holiday  for  the  past  five  years.  He  is 
much  terrified  and  slightly  shaken  in  a  collision.  He  does  not 
know  he  has  been  hurt,  but  not  many  days  go  by  before  he  is  com- 
pletely prostrated,  unable  to  eat  or  sleep,  and  feeling  thoroughly 
ill.  His  business  still  compels  his  own  attention,  and  so  perhaps 
w^eeks  go  by  before  his  obviously  broken  health  and  unfitness  for 
work  necessitate  complete  rest.  It  is  difficult  to  say  how  he  could 
have  acted  otherwise,  but  all  the   circumstances  conduce  to  make 


GENERAL  NERVOUS  SHOCK.  57 

his  illness  a  long  one,  and  to  delay  the  period  of  convalescence 
and  recovery.  For  however  good  his  health  may  have  been  to 
all  appearances  before  the  accident,  his  nervous  system  was  in 
such  a  state  of  tension  that  it  was  likely  to  give  way  unduly  from 
an  adequate  exciting  cause.  This  is  the  unvarnished  story  of  an 
actual  case,  and  there  are  numbers  like  it.  So,  also,  we  may  find 
a  nervous  system  ill-prepared  to  bear  the  brunt  of  a  railway  shock 
in  those  of  intemperate  habits — habits  of  intemperance  not  in 
matters  only  of  food  and  drink,  to  which  the  word  is  supposed 
commonly  to  apply,  but  habits  of  intemperance  also  in  regard 
to  the  sexual  desire.  This  is  in  my  judgment  a  far  more  power- 
ful predisposing  cause  of  the  neurasthenical  state  than  errors  in 
diet  and  alcoholic  excess.  At  any  rate,  such  causes  as  these 
must  be  borne  in  mind  if  we  would  seet  for  the  reason  why  the 
symptoms  are  severe  or  are  being  unduly  prolonged.  Treatment 
is  little  likely  to  be  of  use  unless  they  are  recognised  and  put  out 
of  the  way. 


9.  It  is  a  striking  fact  that  in  cases  where  there  has  been  Absence  of 
serious  injury  to  limb,  stich  as  simple  or  compound  fracture,  even  Symptoms 
if  at  the  time  of  the  accident  the  collapse  was  extreme,  it  is  most  "^  *^']*'^®  °^ 

^  ,  fracture. 

unusual  to  meet  with  the  protracted  after-symptoms,  which  have 
been  described  as  due  to  general  nervous  shock. 

Case  16. — Severe  hodily  injuries — Absence  of  prolonged  after- 
symptoms  of  shock. — A  man,  aged  forty-seven,  was  in  a  very  bad 
collision  at  night,  and  in  addition  to  severe  bruises  and  burns 
about  the  face  and  body,  he  had  a  simple  fracture  of  one  fibula, 
and  a  compound  fracture  of  both  bones  of  the  other  leg  just  above 
the  ankle.  There  was  naturally  great  collapse,  but  he  rallied  in 
the  ordinary  way  and  did  well.  Six  months  after  the  accident 
his  general  health  was  good ;  he  was  well  nourished,  he  had  no 
nervous  symptoms,  his  pulse  was  quiet,  and  sleep  and  appetite 
were  both  excellent.  Nor  were  there  any  after-symptoms,  for 
at  the  end  of  five  years  he  was  reported  as  feeling  no  ill  effects 
whatever  from  the  accident,  save  a  little  pain  and  stiffness  in 
the  ankle  when  the  weather  was  cold.  Never  at  any  time  were 
there  neurasthenical  symptoms. 

What  is  the  reason  that  in  a  case  such  as  this,  and  in  others 
like  it,  there  should  be  so  marked  an  absence  of  the  after-symptoms 
of  general  nervous  shock,  when  originally  the  collapse  was  very 
severe  ?      In  psychical  conditions  lies,  I  believe,  the  explanation 


5  8  EAILWAY    INJURIES. 

of  this  seeming  anomaly.  In  the  very  definiteness  of  the  injury 
there  is  something  on  which  the  mind  of  the  patient  can  dwell 
with  a  certain  measure  of  satisfaction,  for,  as  far  as  he  knows, 
the  usual  result  after  fracture  is  perfect  restoration  of  health  and 
bodily  usefulness.  The  collapse  subsides,  and  the  patient  finds 
himself  with  an  injury  not  more  obscure,  it  may  be,  than  that 
of  a  broken  leg.  He  knows  that  he  has  been  doomed  for  a 
time  to  his  bed,  and  that  as  soon  as  he  is  allowed  to  be  up 
he  will  beofin  to  move  about  agfain  and  to  o^et  well.  The 
injury  is  definite  and  precise,  its  symptoms  are  obvious  from  the 
moment  it  was  received,  it  lacks  the  seeming  obscurity  that  is 
a  feature  of  those  symptoms  which  only  supervene  after  several 
hours  or  days,  there  is  pi'obably  less  pain  as  time  goes  on,  and 
all  the  circumstances  combine  to  induce  a  repose  of  mind,  which 
is  absent  from  the  commoner  cases  which  have  been  considered. 
And  there  is  also  the  necessity  of  complete  bodily  repose  from  the 
moment  that  the  patient  can  be  placed  in  bed.  The  enforced 
rest  is  good  both  for  body  and  mind.  Confinement  to  bed  at  an 
end,  the  patient  is  only  too  thankful  that  he  is  able  to  move 
about  again,  and  gradually  begin  to  walk.  Returning  strength 
goes  hand  in  hand  with  returning  possibility  of  exercise,  and 
there  is  less  excuse  for  staying  indoors  because  of  the  fear  that 
the  after-consequences  of  some  wholly  obscure  injury  maj  turn 
out  very  serious.  There  is,  moreover,  less  likelihood  of  dispute 
arising  as  to  compensation,  and  the  money  calculation  becomes 
all  the  easier  and  the  readier,  because  the  nature  and  extent  of 
the  injury  can  be  definitel}"  appraised.  Thus  the  absence  of  the 
symptoms  of  continued  nervous  shock  in  cases  of  bodily  injury, 
where  the  amount  of  true  collapse  may  have  been  originally 
severe,  throws  light  on  the  symptoms  which  the  more  ordinary 
cases  present,  and  tends  to  support  the  view  that  those  symptoms 
are  due  to  mental  causes  rather  than  to  the  bodily  injury  or  to 
any  vibratory  jar  sustained. 

And  how  largely  the  continuance  of  the  symptoms  is  due  to 
mental  influences  is  shown,  perhaps  even  more  conclusively,  by 
the  speedy  recovery  which  often,  ensues,  when  the  exciting  causes 
of  the  symptoms  are  removed.  It  is  all  very  well  to  say,  it  is 
a  diagnosis  easy  enough  to  make,  that  so-and-so,  who  recovered 
as  soon  as  his  claim  was  settled,  was  shamming,  and  that  his 
symptoms  were  altogether  untrue  or  wilfully  exaggerated  ;  but 
this  will  hardly  suffice  in  explanation  of  the  symptoms  which 
have  caused  so  much  anxiety  and  trouble,  and  have  been  so  little 
amenable   to   treatment.      Suspense  is  at  an  end,  and  there  is 


GENERAL  NERVOUS  SHOCK.  59 

nothing  any  longer  in  the  way  of  his  making  the  requisite  and 
successful  effort  to  resume  his  work.  "  How  long  I  have  been  ill. 
how  little  I  improve,  how  small  seem  the  chances  of  my  recovery," 
have  been  the  uppermost  sentiments  in  his  mind,  and  they 
speedily  give  way  to  this  one,  which  is  wholly  different  and  far 
more  hopeful,  "  How  soon  shall  I  be  well." 


10.  It  remains  to  be  considered  to  what  extent  recovery  is  The  pros- 
possible  in  these  cases  of  nervous  shock,  and  how  far  the  patient  the  futun 
regains  the  mental  and  bodily  vigour  which  he  had  before  the  ^^-'^l^ih. 
accident.  Happily  the  record  of  cases  known  to  me  is  conclusive 
upon  this  point,  that  recovery  is  usually  complete,  and  the  patient 
is  able  to  resume  his  occupation  and  to  carry  on  his  business  as 
well  as  he  did  before.  There  are,  of  course,  exceptions  to  the 
rule,  exceptions  which  show  that  some  alteration  has  taken  place 
in  the  bodily  physique,  and  very  possibly  in  the  mental  vigour 
also.  Thus  you  may  hear  that  the  man  is  less  able  to  bear  pro- 
longed fatigue,  either  bodily  or  mental ;  that  he  is  more  susceptible 
to  the  influence  of  alcohol,  more  irritable  and  easily  excited ;  that 
he  lacks  that  complete  self-control  which  he  may  formerly  have 
had  in  his  business  relations  with  his  fellow-men ;  that  he  is 
nervous  when  travelling,  is  afraid  to  ride  or  drive,  and  has  been 
compelled  to  give  up  his  hunting  and  shooting  ;  that  he  is  a  more 
nervous  man  than  he  was  before,  and  more  subject  to  headaches ; 
and  in  the  severer  cases,  that  his  hair  has  turned  grey,  and  he 
looks  prematurely  aged.  Some  years  have  been  added  to  his  life, 
and  he  is  never  quite  what  he  was  before. 

And  here  very  appropriately  arises  this  important  question, 
How  far  does  the  course  of  the  protracted  illness,  apart  from 
the  nature  of  the  original  injury  and  shock,  conduce  to  imperfect 
recovery  hereafter  ?  Remember  that  the  symptoms  have  been 
largely  those  of  emotional  disturbance,  that  loss  of  control  and 
feebleness  of  will  have  been  at  the  foundation  of  many  of  them, 
and  there  can  be  little  doubt  that  an  unconscious  or  wilful  yield' 
ing  to  every  sensation  that  may  arise,  the  abandonment  of  the 
conscious  self  to  the  thraldom  of  the  morbid  state,  the  enjoyment, 
so  to  speak,  of  the  luxury,  not  of  woe  exactly,  but  of  gloomy  fore- 
bodings and  feelings  and  fears,  pave  the  way  for  the  impossibility 
of  regaining,  even  in  the  best  of  circumstances,  that  complete 
mental  stability  and  continuous  self-control,  which  are  the  happy 
appanage  of  perfect  bodily  and  mental  health.  A  vicious  habit 
is    being   impressed   upon   his   nervous    system,  from  which  the 


6o  RAILWAY    INJURIES. 

sufferer  will  find  it  difficult  to  rid  himself.  If  he  thus  allows 
the  various  influences  conducive  to  the  morbid  state  to  have 
the  mastery  over  him  for  weeks  and  months,  because  he  thinks 
it  better  to  "  wait  and  see  how  things  turn  out,"  unable,  or 
making  no  determined  effort,  to  resume  his  natural  occupation 
and  mode  of  living  until  some  wholly  impossible  compensation 
has  been  received,  depend  upon  it  he  will  suffer  in  the  future. 
Or  worse  than  this,  if  he  keeps  up  the  morbid  state  by  wilful 
means,  his  moral  and  his  physical  nature  are  subjected  to  a  long 
spread-out  shock,  from  which  it  will  be  hard  to  rally.  As  he 
sows  so  also  shall  he  reap. 


CHAPTER  IV. 

THE    FRIGHT   NEUROSES-TRAUMATIC   HYSTERIA. 

SUMMABY. — I.  Neuromimetic  disorders  following  injury. — 2.  Use  of  tlie  term  "func- 
tional."—  3.  The  temperament  and  previous  health. — 4.  Acute  hysteria.  —  5. 
Chronic  neuromimeses  and  the  accompanying  cerebral  state. — 6.  Suggestion  in 
hypnosis. — 7.  Charcot  and  traumatic  suggestion. — 8.  Auto-suggestion  and  fear 
of  paralysis. — 9.  State  allied  to  hypnosis  after  railway  accident. — 10.  Oppen- 
heim's  views. — II.  The  cerebral  state  induced  by  fright. — 12.  Dangers  of  its 
continuance. 

1.   I    PROCEED,   in  the  next  place,   to   the    consideration  of  a  Nenro- 
class  of  cases  to  which  the  name  "  traumatic  hysteria  "  is  now  very  disoixiers 

commonly  afiven.      In  my  former  work  they  were  dealt  with  as  following 

T  .  .  .  injury, 

examples  of  so-called  functional  or  neuromimetic  disorder,   and 

although  I  shall  still  have  to  insist  that  that  is  their  essential 
nature,  the  term  traumatic  hysteria  has  come  into  such  general 
use  in  more  recent  years,  that  though  I  should  prefer  to  call  them 
the  "  fright  neuroses,"  I  intend  to  adopt  it  here.  Objection  has 
from  time  to  time  been  made  to  the  use  of  the  word  "  hysteria  " 
because  of  its  etymology,  and  still  greater  have  been  the  objec- 
tions made  to  it  when  in  company  with  the  word  "  traumatic." 
Nevertheless  I  doubt  very  much  whether  it  will  ever  be  possible 
to  get  rid  of  the  word  hysteria,  or  if  we  should  gain  much  by 
doing  so  ;  and  if  it  be  ever  used  to  signify  the  nature  of  the 
symptoms  presented  by  nervous  disturbance  occurring  in  the 
male,  there  is,  I  venture  to  think,  no  insuperable  difficulty  in  so 
using  it  without  thinking  of  the  womb.  Nor  can  any  reasonable 
person  doubt,  after  perusal  of  the  works  of  Charcot,  Oppenheira, 
Sti'limpell,  Guinon,  Thorburn,  Dreschfeld,  Weir  Mitchell,  and 
many  others,  that  hysterical  disorders  are  prone  to  follow  and  to 
be  the  result  of  injury.  No  better  phrase  for  their  description 
has,  as  far  as  I  know,  been  suggested  than  "  traumatic  hysteria," 
and  I  suppose  there  is  not  a  single  neurologist  of  experience 
or  repute,  who  nowadays  will  be  found  to  deny  that  the  gravest 
disturbance  of  nerve  function,  to  which  the  term  hysteria  is 
more  or  less  ajDplicable,  may  be  met  with  in  the  male  sex,  and 

61 


62  RAILWAY    INJURIES. 

be  the  result  of  injury.  Examples  will  be  given  here  in  support 
of  this  contention,  but  if  any  one  doubts  the  possibility  of  hysteria 
in  the  male,  let  him  turn  to  the  authors  who  have  been  named, 
and  there  he  will  find  unquestionable  instances  which  will  surely 
carry  conviction  to  his  mind. 


Use  of  2.   Do  not  let  it  be  thought,  that  in  speaking  of  symptoms  as 

"  func-       hysterical  or  functional,  there  is  any  desire  to  minimise  their  import- 
tional."       ance  and  it  may  be  their  gravity.      Far  too  often,  it  is  true,  the 
symptoms  of  nervous  disorder  have  been  placed  in  the  category  of 
hysteria,  and  been  forthwith  regarded  as  of  small  concern ;   but 
it   may  be  questioned  whether  the  treatment  of  a  case  has  ever 
been  found  much  easier  because  of  the  diagnosis  of  hysteria,  and  it 
is  tolerably  certain  that  we  are  not  much  nearer  the  correct  under- 
standing of  its  nature  because  it  has  been  so  described.     That  has 
never  been  my  own  feeling  with  reference  to  the  so-called  functional 
disturbances  of  the  nervous  system,  which  are  common  after  rail- 
way accidents.     It  has  always  been  my  opinion  that  some  mate- 
rial and  morbid  change  must  underlie  the  nerve  disorder,  but  it 
seems  to  me  most  unlikely  that  such  change  can  be  of  the  same 
nature  as  the  coarse  pathological  lesions,  which  we  are  wont  to 
see  in  the  post-mortem  room,  or  which  are  shown  us  by  the  micro- 
scope.     For  all  we  know  the  change  may  be  a  chemical  one,  and 
the  nervous  disturbance  be  altogether  secondary.      The  course  of 
the  symptoms  themselves,  and  their  rapid  and  often  very  sudden 
disappearance,  form  well  nigh  conclusive  evidence  that  they  can- 
not be  due  to  gross  pathological  lesion.      Nevertheless,  if,  at  the 
present  day,  we   are   unable  to  say  what  is  the  precise  morbid 
change  underlying  the  so-called  functional  disorders  of  the  nervous 
system,  and  must  acknowledge  with  Guinon  that,  as  far  as  known 
pathological  lesion  is  concerned,  they  are  disorders  sine  matcrid,  we 
are  not  debarred  from  their  clinical  study  ;  nor  is  the  hope  denied 
us  that  a  close  observation  of  the  symptoms  displayed  may  lead 
in  time  to  a  knowledge  of  their  pathology,  whether  the  change  be 
in  the  affected  parts  of  the  nervous  system  themselves,  or  in  their 
nutrition  and  blood  supply. 


The  tem-          3.   From  the  clinical  point  of  view,  then,  we  may  take  it  as  an  i 
andTprevi-  accepted  fact,  that  fright  is  a  common  and  powerful  determining ; 
ous  health,  cause  of  the  onset  of  hysterical  phenomena,  and  it  is  that  element  ) 
in  them  which   makes  railway  collisions  so   fertile  in  functional 


THE    FRIGHT   NEUROSES.  63 

neuromiraetic  disorders.  Apart,  however,  from  the  immediate 
effects  of  fright,  which  is  not  always  or  in  all  cases  followed  by 
injurious  consequences,  there  are  certain  predisposing  conditions 
in  the  individual  which  have  to  be  considered.  The  constitution 
of  the  nervous  system  may  be  itself  at  fault,  either  because  of 
inherited  instability,  or  as  the  result  of  causes  which  have  had 
injurious  influence  upon  it.  Inherited  weakness  may  show  itself 
in  what  is  called  a  nervous  temperament,  such  as  may  be  obvious 
even  to  superficial  observation,  or  as  may  be  brought  to  light  only 
by  illness  or  disease.  We  all  know  how  very  variable  are  the 
effects  of  illness  upon  the  nervous  system,  and  how  often  it 
happens  that  those  who  are  free  from  any  trace  of  nervousness 
during  health  reveal  their  nervous  temperament  when  ill.  And 
even  if  the  hereditary  instability  has  never  been  manifested  in 
themselves,  the  family  history  may  afford  strong  grounds  for 
suspecting  it.'^ 

Moreover,  in  addition  to  the  hereditary  predisposition,  there  are 
predisposing  causes  incidental  to  the  individual  himself.  Eecent 
illness  and  the  consequent  weakness,  sexual  excesses,  overwork  of 
body  or  brain,  alcoholic  intemperance,  the  gouty  diathesis  with  its 
chronic  mal-assimilation  and  impaired  nutrition,  the  existence  of 
some  definite  nervous  disease — all  these  things  and  many  others 
predispose  a  person  to  suffer  from  the  great  mental  shock  which 
appertains  to  a  railway  collision,  and  to  almost  every  serious  accident 
whether  by  land  or  sea.  For  more  detailed  information  on  the 
manifold  predisposing  causes  of  functional  nervous  disorders,  the 
reader  may  turn  with  advantage  and  profit  to  Georges  Guinon's 
recent  work,  Les  Agents  provocateurs  de  VHysterie.  He  will  there 
learn  that  many  of  these  disorders  arise,  not  so  much  as  the 
result  of  an  immediate  cause,  but  from  the  state  of  the  nervous 
system  being  such,  that  an  exciting  cause  is  able  to  provoke  it  to 
the  manifestation  of  functional  disorder.  It  is  in  this  way  that 
railway  accidents  very  often  lead  in  time  to  functional  hysterical 
disturbance,  in  that  by  them  there  is  induced  that  condition,  which 
has  been  dealt  with  in  previous  chapters,  and  to  which  the  term 
neurasthenia  has  been  applied. 

It  seems,  therefore,  an  almost  natural  step  to  pass  from  the 
consideration  of  general  nervous  shock  to  the  consideration  of 
the  cases  of  nervous  mimicry  and  traumatic  hysteria,  because  the 

1  In  his  classical  work  on  hysteria  [De  VHysUrie,  p.  396),  Briquet  records  that 
in  only  ten  out  of  396  women  subject  to  hysterical  disorders  could  he  discover  no 
evidence  of  predisposition.  Thorburn,  Oppenheim,  and  others,  however,  have  had 
a  somewhat  different  experience,  and  do  not  regard  hereditary  predisposition  as  so 


64  RAILWAY    INJURIES. 

shock  has  been,  in  many  instances,  the  means  of  inducing  that 
very  condition  of  the  nervous  system,  which  predisposes  to  the 
manifestation,  and  underlies  the  origin,  of  these  functional  nervous 
disorders.  The  cases  which  will  be  quoted,  moreover,  show  that 
in  the  worst  instances  there  is  frequently  some  evidence  of  mental 
disorder  in  the  previous  history  of  the  patient  himself,  or  that  he 
comes  of  a  stock  in  which  mental  or  emotional  disturbances  and 
peculiarities,  not  necessarily  amounting  to  insanity,  have  been 
recognised  as  prominent  in  the  family  record.  It  has  been  im- 
possible in  every  case  to  obtain  evidence  of  the  kind,  but,  in  the 
absence  of  discoverable  predisposing  tendency,  there  is  a  sufficient 
cause  for  the  origin  of  the  hysterical  disorder  in  the  profound 
nerve  exhaustion,  prostration,  disturbance,  or  whatever  we  may 
like  to  call  it,  which  the  moral  and  physical  shock  of  the  accident 
and  its  varied  consequences  have  had  upon  the  nervous  system. 
We  need  not  seek  further  than  this  for  a  cause  of  the  functional 
disorders — the  paralyses,  the  spasms,  and  the  convulsions — which 
are  mimicries  of  grave  disease. 


Acute  4.   We  may  now  consider  in  greater  detail  the  different  varieties 

ys  eria.  ^^  hysteria  which  are  the  result  of  injury.  In  the  first  place, 
and  of  infinitely  less  moment  than  those  which  have  to  be  spoken 
of  presently,  are  the  convulsive  sobbings,  cryings,  and  laughter 
of  acute  hysteria^  such  as  may  come  on  immediately  after  or 
within  a  few  hours  of  the  accident.  Every  one  is  familiar  with 
these  sorts  of  attacks,  and  I  say  they  are  of  comparatively  small 
moment,  because  they  are  usually  transient.  They  very  probably 
give  relief  to  nervous  tension,  and  are  thus  productive  of  good  ; 
and  experience  tells  that  they  are  not  followed  by,  or  commonly 
associated  with,  those  hysterical  manifestations,  which,  copying 
the  symptoms  of  real  disease,  are  more  determinedly  fixed  in,  and 
are  with  greater  diflficulty  eradicated  from,  the  disordered  nervous 
centre.  They  lack  that  fixity  which  is  one  of  the  most  serious 
and  troublesome  amongst  the  characteristics  of  hysterical  disorder 
of  the  chronic,  as  distinguished  from  the  acute,  variety.  The 
prognosis  is  distinctly  more  favourable,  and  I  shall  say  nothing 
more  about  them  than  this,  that  they  are  to  be  met  with  in  both 
sexes  in  almost  equal  degree,  and  that  it  is  of  importance  to 
ensure  perfect  quietude  and  to  avoid  all  reference  to  the  excit- 
ing cause  of  the  hysterical  seizure.  Condoling  friends  had  better 
keep  out  of  the  way. 


THE    FRIGHT   NEUROSES.  6$ 

5.   Passing,  therefore,  to   the  more   chronic,  rarer,   and  more  Chronic 
imitative  forms  of  traumatic  hysterical  disorder,  the  multiplicity  mimeses 
and  variety  of  the  symptoms,  and  the  very  nature  of  hysteria  itself,  ^"^  ^^ 
render  it  impossible  to  draw  up  any  comprehensive  classification,  panying 
Suffice  it  that  the  symptoms  very  commonly  consist  of  disorders  state. 
of  motion   and  sensation ;   paralyses   or    contractions  of  a  limb ; 
diminution  or  other  impairment  of  common  and  special  sensation  ; 
convulsive  epileptiform  seizures ;  vaso-motor  derangements ;  and 
more  markedly  psychical  troubles.      The  varied  symptoms  are,  I 
think,  best  studied  in  the  record  of  individual  cases,  but  I  propose 
in  the  first  place  to  say  something  as  to  the  possible  origin  and 
nature  of  some,  at  any  rate,  of  the  symptoms  which  may  be  seen. 
In  my  former  work  I  expressed  my  "  belief  that  the  primary  seat 
of  functional  disturbance  lies  in  the  brain  itself,  and  that,  as  in  the 
hypnotic  state  induced  by  a  profound  mental  impression,  there  is 
a  temporary  arrest  in  the  function  of  that  part  of  the  sensorium 
which  presides  over  and  controls  the  movements  and  sensations 
of  the  periphery."      There  can,  I  think,  be  no  question  that  the 
underlying   cause    of  the    neurotic    symptoms,    even    of  such   as 
"  functional  paraplegia,"  is  to  be  found  in  the  cerebral  cortex. 
The  disorder  has  had  its  beginning  in  profound  mental  disturbance 
or  shock,  and  the  presentation  of  the  symptoms  seems  to  direct  one 
entirely  away  from  the  periphery  of  the  nervous  system  in  search 
for  an  explanation.     In  paraplegia  from  organic  disease,  other  than 
that  of  absolute  destruction  of  the  cord,  the  loss  of  motor  power 
and  of  common  sensation  is  rarely  absolute,  and  the  patient,  at  any 
rate,  is  only  too  anxious  to  show  how  much  power  of  movement 
he  has.      In  functional  paraplegia,  on  the  contrary,  the  paralysis 
is  usually  absolute,  nor  can  any  movement  be  elicited  at  all.      The 
thing  at  fault  is  obviously  the  power  of  initiating  movement.     The 
mandate  from  the  brain  is  in  the  one  case  checked  by  lesion  in 
the  cord,  beyond  which  it  makes  its  way  with  difficulty.      It  makes 
it,  however,  and  some  movement  is  the  result.      In  the  other  case 
the   mandate    never  leaves   the   cerebral   cortex    at  all — no  im- 
pression reaches  the  limbs,  and  there  is  no  movement.      When 
we  come  to  consider  individual  cases,  we  shall  see  the  same  sort 
of  defective  power  of  the  cerebral  cortex  in  initiating  movement 
in  such   a  simple  act  as  that  of  putting  out  the  tongue.      Asked 
to  put  out  his  tongue,  the  patient  is  wholly  unable  to  do  so. 
Vigorous  effort  is  made — the  facial  muscles  and  the  muscles  of  the 
trunk  and  limbs  are  called  into  play  as  if  they  could  determine 
the   result;   and   the  result    is  entirely  abortive,   or   the  tongue 
perhaps  reaches  no  further  than  the  teeth  or  lips.     But  if  such 

E 


66  RAILWAY    I^VURIES. 

a  patient  be  carefully  observed,  it  will  be  noticed  that  there  is  no 
impairment  whatever  in  the  movements  of  the  organ  itself :  speech 
is  unaffected,  and  if  by  any  chance  the  automatic  and  involuntary 
act  has  to  be  performed  of  removing  a  particle  of  food  from  the 
outside  of  the  lip,  out  goes  the  tongue  in  a  perfectly  natural  way. 
This  was  a  striking  phenomenon  in  one  of  the  cases  to  be  presently 
recorded,  in  which  there  were  symptoms  of  functional  neurosis, 
such  as  we  may  conceive  could  not  possibly  be  feigned  ;  and  it 
is  the  presence  and  co-existence  of  such  other  symptoms  which 
enable  us  to  establish  it  as  tolerably  certain  that  these  defects  in 
motor  power  ai'e  not  fraudulent,  but  are  likewise  due  to  a  real 
inability  on  the  part  of  the  patient  to  call  his  cerebral  centres 
into  the  activity  requisite  for  the  particular  movements  desired. 
It  may  be  difficult  or  impossible,  mere  conjecture,  to  say  wherein 
the  cerebral  defect  lies,  but  there  seems  to  be  neither  more  nor 
less  difficulty  in  the  case  of  sensory,  than  there  is  in  the  case 
of  motor  disorders.  Both  are  alike  inexplicable  ;  but  if  defect 
of  the  will  power  of  the  higher  cerebral  centres  be  indicated  by 
inability  to  perform  desired  movements,  is  it  altogether  inconceiv- 
able that  the  same  cause  is  at  work  in  the  abolition  of  common 
sensation  and  in  impairment  of  the  special  senses?  Automatic 
movements  continue  unimpaired,  purposive  desired  movements  are 
those  alone  which  fail ;  and  it  has  often  occurred  to  me,  when  in 
the  presence  of  a  case  of  fanctional  anesthesia,  that  the  loss  of 
sensation  may  be  quite  as  much  a  phenomenon  of  the  moment, 
as  is  inability  to  put  out  the  tongue  a  phenomenon  of  the  moment 
when  that  particular  and  specific  act  has  been  desired.  May  not 
sometimes  the  very  examination  of  a  hemianassthetic  patient 
largely  determine  the  hemiangesthesia,  which  forthwith  disappears 
as  soon  as  the  examination  is  at  an  end  ?  Common  sensation,  \ 
for  all  we  yet  know,  may  be  quite  as  much  both  voluntary  and 
automatic  as  is  the  power  of  ordinary  movement ;  and  although 
we  talk  about  a  patient  not  choosing  to  do  this  or  that,  the 
psychical  condition  which  determines  his  inability  to  put  out  his 
tongue  may  equally  determine  his  inability  to  feel,  and  the  loss 
of  the  one  power  may  be  as  much,  or  as  little,  dependent  on  the 
brain  activity  which  we  call  Will,  as  is  the  loss  of  the  other.  At 
any  rate,  both  defects  have  a  common  exciting  cause,  and  that  is 
the  state  resembling  hypnosis  which  is  induced  by  fright. 


Supges-  6.   We  know  how  great  is  the  part  played  by  "  suggestion  " 

hypnosis,     when  the  patient  is  in  the  hypnotic  condition,  and  how  it  may 


THE    FRIGHT    NEUROSES.  6/ 

lead  to  the  manifestation  of  various  motor  and  sensory  disturb- 
ances. The  examination  of  a  patient  may,  therefore,  it  seems 
to  me,  sometimes  provide  the  suggestion  whereby  ansesthesia 
results.  Looked  at  in  this  light,  suggestion  and  expectancy  are 
very  much  the  same  thing ;  and  underlying  each ,  whether  the 
same  or  different,  is  an  abnormal,  and,  for  the  time,  unhealthy 
condition  of  the  higher  cerebral  centres,  whereby  a  change  is 
brought  about  in  the  ordinary  relations  of  mind  and  body.  Let 
it  be  granted  to  the  full  that  the  severe  psychical  disturbance  of 
an  accident,  in  which  there  has  been  reason  for  fright,  is  re- 
sponsible for  all  the  evil  consequences  which  ensue,  yet  I  have 
little  doubt  that  the  resultant  symptoms  are  not  altogether  inde- 
pendent of  the  method  of  procedure  which  is  adopted  for  dis- 
covery of  the  symptoms  present  or  expected.  To  take  a  specific 
instance.  If  it  became  the  custom  to  test  forthwith  the  sensation 
of  every  person  who  has  been  injured  in  a  railway  collision,  we 
should  presently  find  the  opportunities  of  studying  hemianaesthesia 
enormously  increased ;  much  as  in  the  same  sort  of  way,  when 
it  was  the  custom  to  examine  everybody's  spine,  injured  or  no, 
complained  of  or  no,  spinal  tenderness  and  surface  hyper^esthesia 
of  the  back  were  very  much  more  common  than  they  are  at  the 
present  time.  This  is  no  merely  idle  speculation.  Those  who 
have  had  the  opportunity  of  seeing  large  numbers  of  cases  of 
railway  injury  cannot  help  observing  how  much  there  is  of 
fashion  in  the  symptoms  which  are  seen,  and  a  word  of  warning 
is  not,  in  my  judgment,  out  of  place  to-day. 


7.    Students  of  the  works  of  Charcot  know  how  close  in  his  Charcot 
judgment  is  the  alliance  between   many  of   the   phenomena  of  matic  sug- 
hysteria   and   those    which    may   be    purposely   induced    in    the  g^stioa. 
hypnotic  state.      Recognising  the  ease  with  which  many  condi- 
tions, such  as  palsy  or  contracture  of  a  limb  for  example,  may  be 
developed  by  oral  suggestion  during  the  hypnotic  sleep,  he  sees 
a  close  analogy  between  the  origin  of  those  phenomena  and  the 
origin  of  many  of  the  phenomena  of  traumatic  hysteria.     In  place, 
however,  of  oral  suggestion,  it  is  the  injury  which  suggests  the 
special  form  of  neurotic  disorder,  and  traumatic  suggestion  takes 
the  place  of  oral  suggestion  in  hypnosis.      But  as  oral  suggestion 
is  followed  by  the  desired  result  only  when  the  higher  regions  of  the 
cerebral  cortex  are  in  the  hypnotic  state,  so  traumatic  suggestion 
has  no  influence  unless  the  centres  are  in  a  condition  allied  to 
that  in  which  they  can  be   put  in  hypnosis.      The  circumstances 


68  .    RAILWAY   INJURIES. 

in  whicli  the  injury  was  sustained  provide  the  requisite  condition. 
Speaking  of  railway  collisions,  he  says  that  nervous  troubles  often 
occur  in  such  cases  apart  from  any  traumatic  lesion,  and  simply 
as  a  result  of  the  psycho-nervous  commotion  produced  by,  yet 
frequently  not  appearing  immediately  after,  the  accident.  It  is 
the  state  induced  by  the  psycho-nervous  commotion  which  renders 
traumatic  suggestion  possible.  Turn  to  one  of  his  most  typical 
cases  of  hystero-epilepsy  ("  Diseases  of  the  Nervous  System," 
vol.  iii.,  1889,  New  Sydenham  Soc,  tr.  by  Dr.  Savill,  p.  226, 
et  seq.),  where  all  the  prolonged  symptoms  had  had  their  beginning 
from  a  severe  cut  on  the  arm,  on  the  receipt  of  which  the  patient 
had  fallen  to  the  ground  with  hgemorrhage  and  fright.  Was 
the  wound,  he  asks,  sufficient  to  provoke  the  development  of  the 
nervous  symptoms  ?  No,  he  answers  ;  and  he  would  have  us  bear 
in  mind  that  "  along  with  the  injury  there  is  a  factor  which  most 
probably  plays  a  much  more  important  part  in  the  genesis  of 
these  symptoms  than  the  wound  itself.  I  allude  to  the  fright 
experienced  by  the  patient  at  the  moment  of  the  accident,  which 
was  betrayed  shortly  afterwards  by  a  loss  of  consciousness,  fol- 
lowed by  a  sort  of  transitory  paralysis  of  the  lower  extremities." 
The  same  nervous  condition,  which  formed  the  psychical  sub- 
stratum of  the  hystero-epileptic  phenomena  in  that  instance, 
exists  in  all  probability  in  those  cases  where  some  trifling  injury, 
in  the  neighbourhood  of  a  joint,  for  example,  has  led  to  palsy, 
contracture,  or  anaesthesia  of  a  whole  limb,  or  to  the  physical 
signs  and  symptoms  which  imitate  disease  of  a  joint.  The  injury 
was  the  cause  of  some  abnormal  sensation  which  in  a  healthy 
nervous  condition  would  have  been  totally  disregarded,  but  which 
to  a  nervous  system,  the  victim  of  psycho-nervous  commotion, 
fright  or  mental  shock,  becomes  suggestive  of  serious  wrong. 
This,  in  other  words,  is  "traumatic  suggestion,"  and  having 
expressed  similar  views  in  1883,  I  am  now  in  full  accord  with 
Charcot  when  he  says  that  in  railway  collisions  a  "  peculiar 
mental  condition  is  often  developed,  which  is  intimately  con- 
nected, in  my  judgment,  with  the  hypnotic  state.  In  both  of 
these  conditions,  in  fact,  the  mental  spontaneity,  the  loill,  or  the 
judgment,  is  more  or  less  suppressed  or  obscured,  and  sugges- 
tions become  easy.  And  thus  the  slightest  traumatic  action,  for 
instance,  directed  to  a  member  may  become  the  occasion  of  a 
paralysis,  of  a  contracture,  or  an  arthralgia.  It  is  in  this  way 
that  one  so  often  sees  after  railway  accidents  cases  of  monoplegia, 
paraplegia,  or  hemiplegia  simulating  organic  lesions,  although 
they   are  no   other   than   dynamic   or   psychical   paralyses,  very 


THE   FRIGHT   NEUROSES.  69 

analogous,  to  say  the  least,  to  hysterical  paralyses."  This  con- 
dition, so  closely  allied  to  the  hypnotic  state,  may  be  developed 
by  the  nervous  shock,  but  I  believe  that  it  may  be  the  result 
also  of  the  neurasthenia  which  the  nervous  shock  has  initiated. 


8.  It  is  in  such  cases  that  the  term  auto-suggestion  is,  I  think,  Auto-sug- 
more  appropriate  than  traumatic  suggestion  to  indicate  the  origin  fe^ar^o"'^ 
of  the  nervous  phenomena.  Nevertheless,  there  is  no  material  paralysis, 
difference  between  them.  The  thing  essential  for  suggestion  to 
have  any  influence  is  the  special  psychic  state,  induced  immedi- 
ately by  nervous  shock  or  through  the  intermediate  agency  of  the 
general  nervous  depression,  which,  for  the  sake  of  brevity,  we 
call  "  neurasthenia."  And  in  many  other  ways  than  in  affections 
of  the  limbs  and  joints,  auto-suggestion  has,  in  my  opinion,  much 
to  do  with  the  origination  of  symptoms  which  are  clearly  of  the 
nature  of  hysteria.  That  some  form  of  local  paralysis  should  be 
a  very  frequent  result  of  suggestion  is  not  a  matter  of  surprise, 
when  we  remember  how  very  commonly  local  injuries,  and  local 
injuries  of  no  great  severity,  as  has  been  previously  pointed  out, 
are  met  with  by  the  sufferers  in  railway  collisions.  The  sense  of 
heaviness  and  numbness  which  follows  a  blow,  more  especially  if 
in  the  excitement  of  the  moment  the  person  has  been  unconscious 
of  having  been  struck  on  any  one  part,  is  very  likely  indeed 
to  suggest  the  notion  of  paralysis.  It  is  astonishing  how  often 
after  a  railway  accident  one  hears  the  fear  of  paralysis  expressed, 
and  has  to  recognise  how  very  real  this  fear  may  be  to  the  patient, 
and  how  difficult  it  is  to  eradicate  it  from  his  mind.  There  is 
much  truth  in  Mr.  Thorburn's  remark  {op.  cit.,  p.  219)  that  "in 
the  case  of  railway  accidents,  at  any  rate,  the  general  public  of  this 
country  has  been  educated  to  expect  '  concussion  of  the  spine  '  with 
paralysis,  and  that,  in  the  minds  of  the  laity,  the  very  mention 
of  a  railway  accident  calls  up  the  required  idea."  If  the  reader 
will  recall  what  has  been  said  as  to  traumatic  lumbago,  and  the 
symptoms  which  frequently  accompany  it,  he  will  have  no 
difficulty  in  appreciating  Mr.  Thorburn's  remark;  nor  will  he 
hud  cause  for  surprise  that  hysterical  affections  of  the  spine 
should  be  common  after  railway  collisions,  having  as  their  basis 
the  fascial  and  muscular  injuries  which  have  been  described. 

9.  Touching  on  the  subject  of  hypnotism,  the  same  writer  sees  state  allied 

e      x,-   -u         i.-      i.       et-        to  hypnosis 

an  alliance  to  it  in  the  unconsciousness  01  wnicn  patients  orten  after  rail- 
speak,  as  having  affected  them  at  the  tune  of   the  colHsion.     It  ^^^tf^'^'' 


yo  RAILWAY    INJURIES. 

is  a  familiar  fact  that  a  period  of  transient  unconsciousness,  or 
a  period,  at  any  rate,  in  which  there  is  no  conscious  impression  of 
events,  is  by  no  means  uncommon,  even  when  those  who  tell  of  it 
have  had  no  blow  upon  the  head,  and  there  has  certainly  not  been 
concussion  of  the  brain.  I  have  myself  regarded  this  as  a  dazed 
condition,  the  result  of  fright,  and  have  never  thought  it  strange 
that  some  persons  should  have  been  wholly  unable  to  give  any 
account  of  what  transpired,  or  what  they  themselves  did  after 
a  collision,  when  one  bears  in  mind  how  terrible  may  be  the 
accompanying  events  of  a  severe  collision,  and  how  vast  and 
appalling  is  the  contrast  between  everything  before  it  and  every- 
thing after.  Mr.  Thorburn,  however,  goes  further  than  this,  and 
is  inclined  to  regard  this  state  of  daze  as  of  the  same  nature  as 
the  state  of  hypnotism,  and  thereby  he  finds  an  explanation  of 
the  many  strange  and  unremembered  acts  of  persons  thus  affected, 
and  of  the  imaginative  and  altogether  incredible  stories  which 
they  may  tell  of  what  befell  them,  but  which  they  themselves, 
nevertheless,  implicitly  believe.  He  records  examples  of  this 
nature,  to  one  of  which  I  may  refer  here,  because  it  is  the  history 
of  a  man  known  both  to  Mr.  Thorburn  and  myself,  and  because 
there  was  no  question  of  compensation  to  throw  doubts  on  his 
veracity. 

"  A  gentleman  while  travelUng  with  me,"  writes  Mr.  Thorburn, 
"  allowed  the  train  in  which  he  should  have  proceeded  to  leave 
a  side  station  without  him.  Seeing  the  train  already  started,  he 
ran  after  it,  attempted  to  get  on,  and  fell  on  the  line,  sustaining 
fortunately  no  serious  injury.  He  afterwards  described  minutely 
how  he  had  tried  to  get  on  to  the  third  carriage  from  the  rear 
of  the  train,  but  failing,  had  fallen  behind  it,  and  how  the 
remaining  coaches  had  then  passed  over  him.  To  this  account 
he  always  adhered,  although  several  railway  servants  who  saw 
the  occurrence  noticed  that  he  jumped  at  and  missed  the  last 
carriage,  and  fell  behind  the  whole  train,  nothing  passing  over 
him." 

Clearly  in  this  instance  there  was  the  psychic  state  in  which 
auto-suggestion  might  have  played  a  part  in  the  development  of 
some  symptom  of  traumatic  hysteria  had  there  been  any  local 
injury  to  determine  it.  This  is  what  happened  in  the  case  of 
one  of  Charcot's  patients,  the  history  of  which  is  recorded  in  the 
appendix  to  his  lectures.  Omitting  many  of  the  symptoms,  it 
may  be  said  that  this  was  a  case  of  paraplegia  following  an  injury, 
severe  contusions  to  the  thighs  and  lower  abdomen,  which  the 
man  described  as  having  been  caused  by  a  heavy  van  passing 


THE    FRIGHT   NEUROSES.  7  I 

completely  over  him.  The  occurrence,  as  he  believed  it  to  have 
taken  place,  came  before  him  often  in  his  dreams ;  but  it  was 
known,  as  a  fact,  that  he  had  not  been  injured  in  this  way  at  all, 
but  that  he  had  been  violently  knocked  down  on  the  footpath 
while  he  was  drawing  his  barrow.  He  lost  consciousness  imme- 
diately, remained  comatose  for  several  hours,  and  afterwards  for 
two  or  three  days  was  in  a  state  of  intellectual  torpor,  in  the 
condition  suitable  for  the  efficacy  of  suggestion.  And  the  sug- 
gestion here  was  made  by  the  abnormal  sensations  in  the  limbs 
which  were  the  consequence  of  the  local  injury.  The  mental 
condition  which  this  man  presented  is  precisely  that  which,  in 
varying  degrees  of  duration  and  severity,  may  be  induced  by  the 
profound  psychical  commotion  of  a  railway  collision.  In  it  the 
affected  person  may  do  things  of  which  he  has  no  subsequent 
recollection,  he  may  be  led  to  believe  that  things  happened  to 
himself  which  are  altogether  contrary  to  fact,  and  any  local 
injury  may  thereby  be  made  the  starting-point,  through  sugges- 
tion, of  some  definite  hysterical  disorder. 


10.  The  all-powerful  influence  of  psychical  commotion  and  Oppen- 
emotion  is  the  very  root  and  foundation  also  of  the  teaching  of  views. 
Oppenheim,  in  his  short  but  most  valuable  work  on  the  trau- 
matic neuroses  {Die  traumatischen  Neurosen,  Berlin,  1889).  The 
physical  injury,  he  tells  us,  is  only  in  part  answerable  for  the 
consequences  which  follow.  "  Die  Rauptrolle  spiclt  das  psycMsche  : 
der  Schreck,  die  GemiUhserschutterung."  His  cases  were  mostly 
those  of  hospital  patients,  and  although  they  were  regarded 
from  a  somewhat  different  point  o£  view,  in  that  he  looks  on  the 
symptoms  of  each  case  as  indicative  of  a  more  definite  psycho- 
neurosis,  yet  this  author  is  in  practical  accord  with  what  has 
been  written  in  the  last  chapter.  It  was  there  insisted  that  the 
psychical  disturbance  was  the  reason  why  the  pain  of  some 
trifling  injury  became  so  magnified  as  to  suggest  all  sorts  of  grave 
and  enduring  disorders.  The  injury  has,  of  course,  as  Oppenheim 
says,  a  direct  result ;  but  as  a  rule  this  is  of  small  and  transient 
moment,  unless  the  mental  disturbance  should  alter  its  usual  char- 
acter and  impress  on  the  bodily  disorder  the  features  of  a  lasting 
disease.  The  influence  of  fright  at  the  time  of  the  accident  is 
so  great  as  to  induce  a  long-continuing  psychical  disturbance, 
and  this  it  is  which  determines  and  governs  the  phenomena  of 
the  traumatic  neurosis.  A  very  careful  study  of  his  writings 
leads  me  to  the  conclusion  that  there  is  no  very  great  difference 


72  RAILWAY    INJURIES. 

between  the  views  of  Oppenheim,  and  those  which  have  been 
advanced  by  myself.  He  lays  greater  stress,  perhaps,  on  the 
psychical  element  in  the  neuroses  and  less  on  that  of  nerve  pros- 
tration, but  both,  it  must  be  remembered,  are  neuroses  of  trau- 
matic orisfin. 


The  cere-  11.  '^  Die  HauptfolU  spiclt  clas  psycMsche  :  der  Schrech,  die 
induced  by  GemuthserscJiutterung" — The  whole  sensorium,  apparently,  may  be 
fright.  j^}ius  affected,  and  may  pass  into  a  state  of  slumber,  as  is  shown  by 
mental  hebetude,  by  lessened  volitional  power,  by  anaesthesia  and 
analgesia,  and,  on  the  other  hand,  also  by  excessive  activity  of 
the  lower  automatic  centres  from  lost  or  torpid  cerebral  control. 
The  abnormal  condition  is  allied  in  all  probability  to  that  of  the 
hypnotic  sleep,  and  it  is,  moreover,  akin  to  it  in  the  readiness 
with  which  the  symptoms  may  pass  away  when  the  requisite 
stimulus  has  aroused  the  brain  from  its  torpid  state.  The 
stimulus  may  be  some  profound  mental  or  bodily  impression ;  it 
may  be  exerted  only  by  the  more  tedious  influence  of  re-education 
of  the  movements  of  the  afiected  part ;  but  in  either  case  the 
activity  of  the  sensorium  is  once  more  alert,  and  the  cerebral  con- 
trol can  be  exercised  in  its  normal  and  healthy  way.  Not  less 
mysterious  than  slumber  of  the  sensorium,  whether  it  be  of  the 
whole  or  of  a  part,  is  the  fact  that  daily  familiarity  with  the 
morbid  process  seems  to  give  the  individual  patient  the  volun- 
tary and  more  facile  power  of  putting  the  affected  region  of  the 
sensorium  into  the  state  of  torpor,  or  of  voluntarily  abandoning 
himself  to  the  easily  induced  influence  of  the  abnormal  condition. 
Repetition  and  perpetuation  of  the  morbid  condition  of  the  sen- 
sorium make  the  symptoms  easier  of  production  than  they  were 
before.  The  man  who  has  once  been  hypnotised  can  be  more 
readily  hypnotised  again,  and  thus  it  is  that  in  course  of  time 
the  "  medium  "  of  the  mesmerist  or  of  the  so-called  spiritualist 
can  be  reduced  by  the  most  trumpery  and  frivolous  influences  to 
the  hypnotic  or  cataleptic  state,  and  so  becomes  the  most  pitiable 
of  mortal  men. 


Dangers  of       12.   It  has  been  said  already,  in  speaking  of  the  symptoms  of 

tinuance.     general  nervous  shock,  that  the  man  who  voluntarily  abandons 

himself  to  the  morbid  state  submits  both  his   moral  and  physical 

nature  to  a  long  spread-out  shock  from  which  he  will  find  it  hard 

to  rally,  and  the  same  remark  may  be  here  reiterated  with  even 


THE    FRIGHT   NEUROSES.  73 

greater  force  in  connection  with  the  functional  disorders  which 
are  results  of  the  unnatural  nervous  state.  For  there  can  be 
no  doubt  whatever  that  many  neuromimetic  conditions  are  more 
or  less  under  the  voluntary  control  of  the  patient ;  and  that,  as 
may  be  seen  in  cases  of  convulsion,  the  mimetic  seizures — in  them- 
selves typical  in  character — may  be  brought  on  by  the  will  of  the 
patient  himself.  And  this  can  be  done  with  greater  ease  as  time 
goes  on.  Herein  lies  the  explanation  of  those  happily-timed  con- 
vulsions which  occur  when  it  is  most  important  that  you  should 
see  them,  and  should  be  impressed  by  their  severe  reality.  The 
seizure  itself — qua  seizure — is  typical  of  its  kind,  and  its  pheno- 
mena lie  outside  the  conscious  control  of  the  individual.  But  within 
his  control  has  been  the  commencement  of  the  seizure  at  the  precise 
moment  when  it  began.  Thus,  in  speaking  of  the  ease  with  which 
the  hypnotic  state  may  be  induced  in  those  who  have  been  often 
hypnotised,  Heidenhain  writes  :  "  Many  of  the  gentlemen  upon 
whom  the  above  experiments  have  been  made,  need  only  to  sit 
down,  close  their  eyes,  and  think  intently — other  thoughts  being 
excluded — that  the  hypnosis  is  coming  on,  in  order  to,  as  it  were, 
voluntarily  submit  themselves  to  the  charm."  ^  And,  as  of  the 
hypnotic  state,  so  of  other  neuromimeses  also,  the  patients  may 
voluntarily  submit  themselves  to  their  exhibition,  and  the  mani- 
festations thereof  become  in  themselves  not  less  real.  The  exist- 
ence of  a  certain  amount  of  control  is  shown,  moreover,  by  the 
disappearance  of  the  mimicries,  when  all  cause  for  their  representa- 
tion is  removed.  The  matter  of  compensation,  as  we  have  seen, 
exerts  in  many  cases  a  very  favourable  influence  on  the  symptoms 
of  general  nervous  shock.  It  does  so  in  these  cases  also,  and 
examples  are  not  few  in  which  typical  neuromimetic  phenomena 
came  to  an  end,  shortly  after  settlement  of  claim  had  secured  for 
the  patients  complete  repose  of  mind,  and  had  freed  them  from 
the  necessity  of  any  longer  allowing  themselves  to  be  their  victims 
and  exponents. 

In  speaking  of  the  objections  made  to  hypnotic  experiments, 
Heidenhain  seeks  to  show  that  the  repetition  of  them  does 
not  appear  to  be  fraught  with  danger  or  evil,  but  he  mentions 
cases  where  attacks  of  convulsions  constantly  accompanied  every 
hypnotic  experiment,  and  one  patient  who  suffered  after  every 
experiment  from  a  certain  degree  of  nervous  irritability  which 
lasted  twenty-four  hours.^  I  have  myself  no  doubt  that  the  risk 
of  permanent  damage  to  the  stability  of  the  nervous  system  and 
tone  must  be  very  considerable  in  all  persons  who  repeatedly 
^  Animal  Magnetism,  p.  86.  -  Op.  cit.,  p.  102,  et  seq. 


74  RAILWAY    INJURIES. 

submit  themselves,  whether  vokmtarily  or  involuntarily,  to  the 
hypnotic  state,  even  though  it  is  not  accompanied  by  convulsions 
or  is  not  followed  by  "  nervous  irritability."  The  hypnotic  state 
is  not  a  natural,  it  is  a  morbid  state  ;  to  repeat  it  is  to  perpetuate 
it,  and  make  it  an  abiding  part  of  the  organisation  of  the  individual. 
Not  less  does  risk  of  permanent  damage  to  the  stability  of  the 
nervous  system  lie  in  long  continuance  of  any  functional  mimetic 
disorders.  The  longer  they  exist  the  more  prone  are  they  to  give 
rise  to  lasting  nervous  disturbance,  and  to  the  phenomena  which 
may  be  the  result ;  and  even  in  cases  where  the  neuromimeses  pass 
away  under  returning  cerebral  control,  the  risk  is  by  no  means  small 
that  from  some  exciting  cause  the  conditions  may  be  very  readily 
reproduced.  The  lesson  to  be  learned  from  this  is  obvious,  that 
the  sooner  any  cause  for  the  representation  of  the  phenomena  is 
removed  the  better,  and  that  the  patients  should  as  far  as  possible 
be  freed  from  the  hurtful  sympathy  of  friends.  There  is  little 
chance  of  improvement  or  cure  as  long  as  the  patient  need  not 
make  the  necessary  effort  to  get  well,  and  as  long  as  his  friends, 
in  ignorance  of  the  real  nature  of  his  malady,  foster  by  mis- 
directed sympathy  and  kindness  those  very  symptoms  whose  con- 
tinuance is  fraught  with  danger  to  the  stability  of  his  nervous 
system.  The  question  of  diagnosis  is  thus  all-important,  and  once 
established  it  is  doing  him  a  grievous  wrong  if  his  sufferings 
and  symptoms  are  to  be  made  the  occasion  of  litigation  and 
prolonged  dispute. 


CHAPTER  V. 

THE   FRIGHT   NEUROSBS-(ConetnM«d). 

Summary. —  l.  Examples  :  Functional  paraplegia  in  women,— 2.  In  men. — 3.  Hys- 
terical seizures  suggested  by  syncope. — 4.  Vomiting  and  its  suggestion. — 5. 
Hemiansesthesia  in  men. — 6.  The  moral  aspect  of  hemiansesthesia. — 7.  Hypnotic 
catalepsy  in  men. — 8.  Three  types  of  the  fright  neuroses. — 9.  Occasional  mental 
disorders. 

1.   I  SHALL  now  illustrate  the  foregoing  remarks  by  the  brief  Examples: 
record   of  several  cases,   the   symptoms   of  which   will   suggest  parTpi'eda 
various  comments  as  we  go  on.      I  adopt  this  plan  because  the  *°  women, 
multiplicity  and  variety  of  the  so-called  functional  disorders  pre- 
vent any  suitable  classification  of  them,  and  because  this  is  not 
a  text-book  of  nervous  diseases.      Information  is  at  hand,  and 
must  be  sought  elsewhere,  as  to  the  condition  of  the  reflexes,  for 
example,  in  the  different  diseases  of  the  nervous  system,  organic 
and  hysterical,  and  only  passing  reference  will  be  made  to  these 
and  other  indications  of  nervous  disorder. 

Case  i6a. — Case  of  functional  paraplegia — JRajncl  recovery  after 
settlement  of  claim. — V.  S.,  a  widow,  aged  thirty-eight,  the  strong 
and  healthy  mother  of  seven  children,  was  in  a  collision.  There  was 
no  history  of  her  having  been  much  hurt  at  the  time,  but  within 
a  few  hours  she  began  to  have  a  pain,  or  a  sensation  which  she 
described  as  "  opening  and  shutting,"  in  the  small  of  her  back. 
The  next  morning  she  continued  her  journey  of  nearly  200 
miles,  and  finding  that  in  a  few  days  the  pain  in  her  back  was 
a  good  deal  worse,  she  went  to  a  hospital.  She  was  an  in- 
patient in  the  hospital  for  six  weeks,  during  the  first  three  of 
which  she  was  in  bed,  suffering  from  pain  and  stiffness  in  the 
small  of  the  back  and  from  general  weakness.  For  three  weeks 
she  was  up  and  moving  about  the  wards,  and  she  then  made 
a  journey  of  330  miles  in  order  to  take  one  of  her  children 
to  school.  This  business  over,  she  then  travelled  home  to  the 
place   where   the    accident   had   originally  happened.       This  was 

75 


'j6  RAILWAY    INJURIES. 

exactly  two  months  after  the  accident,  and  as  soon  as  she  got 
home  she  at  once  took  to  her  bed,  suffering  from  great  pain  in 
the  back,  from  much  hyperaesthesia   in  the  dorsal  and  lumbar 
regions,    and   from    general    prostration.      She    remained   almost 
entirely  in  bed  until  about  fifteen  weeks  after  the  collision,  when 
it  was  accidentally  ^  discovered  that  she  had  lost  all  motion  and 
sensation   in   the   legs.      She    had   complete    control    over    both 
bowel  and  bladder,  and  there  was  neither  wasting  of  the  legs  nor 
bed-sores.     The  paralysis  of  motion  and  sensation  seemed  absolute. 
The  woman  was  at  the  same  time  exceedingly  "hysterical,"  and 
complained  fearfully  of  pain  in  the  back  and  of  innumerable  queer 
sensations  in  different  parts  of  the  body.     The  opinion  was  given 
that  this  paraplegia  was   not  dependent  upon  organic  disease ; 
that  it   was   not   feigned ;   and  that,   although  there    was    every 
prospect  of  her  recovery,  it  was  quite  impossible  to  say  how  long 
she   might  suffer  from  the  paralysis,  or  how  soon  she  might  be 
well.      She  was  attended  throughout  this  illness  by  a  trustworthy 
nurse,  and  there  was  never  any  suspicion  that  the  woman  was  wil- 
fully maintaining  her  condition.     No  material  change  took  place  in 
her  condition  up  to  six  months  after  the  accident,  when  her  claim 
was  settled.     Within  a  fortnight  she  left  the  house  where  she  had 
been  staying,  and  in  three  months  she  was  walking  about  without 
assistance  in  perfect  health.      Further  account  of  her  cannot  be 
obtained.      It  is  open,  of  course,  to  any  one  to  remark  that  this 
was   a   case   of  malingering.      I    do  not   take   this   view,   and  I 
think  it  of  greater  interest  to  consider  what  were  the  circum- 
stances conducive  to  the  paraplegia,  and  what  were  those  which 
brought  about  her  recovery.      There  can  be  no  doubt  that  the 
woman  received   a  sprain  of  her  vertebral  column,  and  that  she 
had  some  "  shock  "  ;   but  of  greater  moment  in  the  history  of  the 
case  is  the  fact  that  the  long  and  fatiguing  journeys,  Avhich  she 
took  within  a  short  time  of  the  accident,  must  have  been  largely 
instrumental  not  only  in  preventing  complete  recovery  from  the 
early  prostration,  but  even  in  increasing  the  general  weakness 
from  which  she  suffered.      After  the  first  journey  she  was  com- 
pelled to  go  to  a  hospital,  and  after  the  second  and  longer  journey 
she  was  so   much   exhausted   that   she   had   at   once   to^^take   to 
her  bed. 

^  "  Accidentallj',"  because  this  is  just  what  so  frequently  happens  in  hysterical 
affections.  "It  is  necessary  to  bear  in  mind,"  Charcot  says,  "that  hemianesthesia 
is  a  symptom  which  requires  to  be  sought  for,  as  M.  Lasegue  very  judiciously  re- 
marks. There  are,  in  fact,  many  patients  who  are  quite  surprised  when  its  existence 
is  revealed  to  them." — Charcot,  Diseases  of  the  Nervous  System,  New  Syd.  Soc, 
1877,  p.  250. 


THE    FRIGHT    NEUROSES.  ^y 

In  two  other  cases  of  paraplegia,  occurring  in  young  girls, 
there  was  very  much  the  same  sort  of  history.  One  of  them  was 
remarkable  in  this,  that  after  the  collision  the  girl  lay  in  a  dazed, 
semi-unconscious  state  for  a  couple  of  hours,  having  received  no 
injury  beyond  a  slight  bruise  on  the  middle  of  her  back  by  the 
fall  of  a  box  from  the  carriage  rack.  Movement  was  painful, 
and  she  took  to  her  bed,  gradually  losing  thereafter  the  use  of 
her  legs.  They  became  extremely  cold,  but  there  was  no  other 
alteration  in  nutrition,  and  the  reflexes  were  quite  normal.  No 
improvement  took  place  in  this  case  until  the  patient  had  been 
taken  from  home,  placed  in  a  hospital,  and  there  put  under 
suitable  treatment.  It  is  probable  that  the  feebleness  of  circula- 
tion and  coldness  of  the  extremities  often  noted  in  these  cases, 
together  with  the  pain  induced  in  moving  the  legs,  provide  the 
"  suggestion  "  to  the  sensorium  which  results  in  loss  of  motion 
and  sensation.  And  let  it  be  noted  that  the  effect  of  the  acci- 
dent was  to  produce  that  condition  of  daze  to  which  reference 
has  been  already  made,  and  to  which,  in  the  astiology  of  such 
affections,  considerable  importance  must  be  attached.  The  legs 
of  the  other  girl  were  equally  cold,  and  in  addition  to  the  para- 
plegia, she  presented  this  characteristic  symptom,  flexion  of 
and  inability  to  extend  the  fingers  when  asked  to  do  so, 
although  in  all  automatic  movements  there  was  no  impairment 
or  defect. 

The  way  in  which  cases  of  this  kind  frequently  recover  shows 
pretty  conclusively  that  the  morbid  seat  is  in  the  brain.  A  sudden 
impression  which  compels  the  automatic  use  of  the  legs  may  in 
a  moment  arouse  the  torpid  sensorium,  or  a  process  of  re-educa- 
tion, beginning  at  the  very  beginning,  as  it  were,  may  be  needful 
to  restore  the  lost  movements  of  the  limbs  by  reawakening  the 
brain  to  a  full  sense  of  its  responsibilities  in  the  circle  of  the  will. 
Cases  like  these  may  look  like  fraud,  but  I  feel  sure  that  Paget  is 
right  when  he  says  that  in  many  of  them  the  "  fault  is  rather  in 
weakness  of  the  will  than  in  its  perverse  strength."  The  patient 
says,  "  as  all  such  patients  do,  '  I  cannot ; '  it  looks  like  '  I  will 
not,'  but  it  is  '  I  cannot  will.' "  ^ 

2.  The  cases  of  functional  paraplegia  which  have  been  recorded  In  men, 
were  very  typical  of  their  kind,  but  we  shall   do  well  to  draw 
remaining  examples  from  patients  of  the  sterner  and,   usually, 
less  hysterical  sex. 

^   Clinical  Lectures  and  Essays,  pp.  i88,  189. 


7S  RAILWAY    INJURIES. 

Case  17. — Case  of  fanctional  motor  paraplegia — Extreme  emo- 
tional disturbance — Ultimate  recovery. — T.  B.,  aged  forty-one,  a 
man  of  gouty  family,  naturally  very  excitable,  and  able,  as  he 
said,  to  hear  a  pin  drop  in  the  next  room,  was  in  a  very  severe 
collision  in  which  the  carriage  he  was  in  was  smashed  to  pieces. 
He  crawled  out  of  the  debris  as  best  he  could  and  went  on  his 
journey,  but  in  about  half-an-hour  he  began  to  have  retching, 
pains  in  the  abdomen,  and  shivering.  He  therefore  returned 
home.  There  were  slight  bruises  about  the  limbs,  and  one  on 
the  forehead;  and  the  next  day,  when  in  bed,  he  complained  of 
pain  in  the  right  side  of  the  abdomen  and  the  lower  part  of  the 
back,  but  at  neither  of  these  places  was  there  mark  or  tenderness. 
For  the  next  few  days  he  seemed  very  ill,  had  severe  pain  in  the 
head,  occasional  retching,  and  at  night  he  wandered.  For  three 
days  his  temperature  was  raised.  He  was  in  a  highly  nervous 
state,  and  spoke  frequently  of  a  dread  of  lock-jaw  and  paralysis. 
Three  weeks  after  the  accident  he  still  complained  of  severe  pain 
about  the  sacral  region,  but  there  was  no  tenderness.  He  com- 
plained also  of  "  numbness  "  in  his  legs,  a  word  used  by  him  to 
express  not  impaired  sensation,  but  a  difficulty  which  he  felt  in 
moving  them.  There  was  no  hyper-  or  an-sesthesia,  but  his 
walking,  in  which  he  helped  himself  by  holding  on  to  the 
furniture,  was  done  with  apparent  fear  and  effort.  He  could 
stand  quite  well  with  his  eyes  shut,  and  there  was  no  spasm  of 
the  muscles  of  the  legs.  His  temperature  and  pulse  were  normal, 
and  the  bodily  functions  were  naturally  performed.  His  general 
condition  improved,  he  was  able  to  eat  and  sleep  better,  and  even 
to  get  out  of  doors  in  a  chair.  He  still  suffered,  however,  from 
extraordinary  emotional  disturbance,  was  very  irascible,  and  fre- 
quently cried.  He  continued  to  dwell  on  the  fear  of  paralysis, 
and  steadily  lost  the  power  of  moving  his  legs.  He  made  for 
himself  an  ingenious  contrivance  whereby  he  was  able  to  move 
about  by  the  support  of  his  arms,  but  his  legs  were  hardly  used 
at  all  in  progression.  Eight  months  after  the  accident  he  was 
quite  unable  to  walk,  and  failed  entirely  to  make  any  requested 
movements  of  the  legs  or  feet  during  examination.  The  attempt 
to  move  his  legs  produced  great  mental  agitation.  There  was 
no  paralysis  of  bowel  or  bladder,  and  sensation  of  the  legs  was 
but  very  slightly,  if  at  all,  impaired.  There  was  no  material 
wasting.  The  cremasteric  reflex  ^  was  normal.  There  was  no 
rigidity  or  spasm,  and  no  sign  of  bed-sore. 

^  This  case  was  seen  before  the  value  of  patellar  and  other  reflexes  was  known, 
and  the  cremasteric  alone  was  tested. 


THE   FRIGHT   NEUROSES.  79 

Nine  months  after  the  accident  he  had  an  attack  of  aphonia, 
brought  on  suddenly  by  hearing  of  the  death  of  a  friend.  The 
aphonia  lasted  for  three  weeks,  and  then  disappeared  as  suddenly 
as  it  began,  when  startled  by  one  of  his  children  rushing  into 
the  room.  He  also  suffered  from  frequent  nausea  and  retching, 
the  least  excitement,  such  as  the  visit  of  a  friend,  almost  certainly 
making  him  sick.  It  is  indeed  very  difficult  to  express  in  words 
how  extreme  was  the  emotional  disturbance  in  this  patient.  He 
had  always  been  a  man  of  highly  nervous  temperament,  likely, 
so  it  was  said,  to  suffer  severely  from  the  shock  of  a  railway 
accident. 

I  satisfied  myself  that  the  paralysis  was  not  dependent  on 
organic  lesion,  and  eleven  months  after  the  accident  reported  to 
the  railway  company  that  the  "  cause  of  the  paralysis  seems  to 
lie  rather  in  the  directing  power  of  the  will  than  in  lesion  dis- 
coverable of  the  brain  or  spinal  cord."  I  had,  moreover,  no 
doubt  that  the  case  w^as  perfectly  genuine,  but  felt  that  it  was 
impossible  to  say  how  long  he  might  be  ill,  and  that  litigation 
would  be  exceedingly  detrimental  to  him.  The  man  himself  was 
advised  to  make  every  effort  to  use  his  legs,  and  to  re-educate 
the  movements  of  them  by  daily  practice.  Litigation  was 
avoided,  and  the  claim,  naturally  and  rightly  a  large  one,  was 
amicably  settled  thirteen  months  after  the  accident.  By  the 
kindness  of  his  medical  attendant  I  had  frequent  reports  of  this 
man  after  his  claim  was  settled.  For  long  he  did  nothing,  and 
remained  in  a  nervous  hysterical  state,  and  it  was  not  until  four 
years  after  the  accident,  when  he  made  a  complete  change  in 
his  living  and  occupation,  that  he  began  to  get  well.  Seven 
years  after  the  accident,  in  the  course  of  the  year  1882,  this 
was  his  own  story,  and  it  speaks  better  of  his  condition,  past 
and  present,  than  any  other  words.  He  considers  that  he  was 
ill  for  between  four  and  five  years.  He  used  the  apphances  for 
walking  for  about  two  years,  and  then  began  to  use  sticks.  Two 
years  and  a  half  ago  he  took  a  public-house  in  the  country,  and 
began  to  lead  an  outdoor  active  life.  When  he  first  began  this, 
he  could  not  get  up  from  his  chair  alone,  having  either  to  be 
helped  up,  or  to  pull  himself  up  by  getting  hold  of  something 
in  front  of  him.  Suddenly  one  day  he  got  up  without  knowing 
it,  and  his  son  said  to  him,  "  Why,  father,  look  what  you've  done  ! " 
"  Good  God  !  "  he  replied,  "  I  have  got  up  myself."  From  that 
day  forth  he  was  able  to  get  up  without  difficulty.  He  still 
has  great  fear  about  his  spine,  and  only  a  few  weeks  ago,  when 
a  friend  struck  him  in  the  back  in  joke,  he  was  terribly  alarmed. 


8o  RAILWAY   INJURIES. 

and  for  two  days  could  hardly  walk.  He  can  walk  nine  miles 
without  fatigue  and  ride  all  day,  he  has  gained  weight,  and  is 
altogether  stronger  and  better  than  he  was  before,  regarding  his 
recovery  as  due  to  change  of  life  and  scene.  In  appearance  he 
was  at  this  time  the  picture  of  health,  and  as  far  as  his  legs  were 
concerned  there  was  not  a  sign  or  symptom  of  anything  whatever 
amiss  with  them,  reflexes  and  nutrition  being  perfectly  normal. 
I  saw  liim  again  in  1890  in  perfect  health.^ 

Case  i  8. — Supposed  spinal  injury — Spasmodic  tivitchings  of  one 
arm,  &c. — S.  B.,  aged  thirty-three,  was  in  a  railway  collision 
at  night,  when  a  large  number  of  persons  were  more  or  less 
shaken  and  hurt.  He  himself  was  not  injured,  as  far  as  he 
knew,  at  any  one  place,  and  no  marks  of  external  injury  were  at 
any  time  discoverable.  He  complained,  however,  of  being  shaken, 
and  looked  pale  and  ill.  He  took  to  his  bed,  and  m  a  few  days 
complained  very  much  of  his  back,  and  was  in  a  continued  state 
of  alarm  about  his  "  spine."  Beyond  appearing  shaken  and 
nervous  about  huuself,  he  had  no  sign  of  structural  injury  to 
any  one  part  of  the  body.  He  remained  in  this  negative  con- 
dition for  some  weeks,  and  then  began  to  move  about  the  house, 
and  once  or  twice  he  went  out  of  doors.  About  this  time  there 
came  on  a  pecuhar  twitcMng  in  the  left  arm,  which  is  thus 
recorded  in  the  notes : — "  To-day  on  my  arrival  he  was  lying 
dressed  on  his  bed.  I  asked  him  to  go  into  the  next  room, 
and  he  got  up  without  apparent  difficulty  and  did  so.  He  sat 
down  in  an  easy  chair,  when  his  left  arm  and  hand  at  once  began 
to  jerk  with  sharp  clonic  spasms  or  twitchings,  not  unlilce  the 
movements  of  chorea.  The  movement  kept  on  when  his  arm 
was  held,  and  he  said  he  could  not  control  or  arrest  it.  It  was 
noticeable,  however,  that  it  ceased  entirely  when  he  began  to 
undress,  partially  ceased  when  he  engaged  in  conversation,  and 
altogether  stopped  when  his  attention  was  specially  directed  to 
some  other  part  of  his  body.  Coincident  with  this  movement  of 
the  arm  was  a  continuous  jerking  of  the  head.  There  was  no 
wasting  nor  any  sign  of  loss  of  power  in  the  limbs."  He  com- 
plained greatly  of  his  back,  and  e"sdnced  tenderness  on  touch  at 
the  mid-dorsal  and  upper  sacral  regions.  The  temperature  was 
normal,  and  all  the  bodily  functions  were  naturally  performed. 
He  continued  in  much  the  same  condition  for  nearly  a  year,  a 

^  See  a  remarkable  case  recorded  by  Dr.  Webber  {Boston  Medical  and  Surgical 
Jouriud,  vol.  X.  p.  44,  1872),  "  Recovery  after  four  years'  paralysis  following  railroad 
injury." 


THE   FRIGHT   NEUROSES.  8 1 

severe  injury  to  the  "  spine  "  being  made  the  basis  of  a  demand 
for  large  pecuniary  compensation.  There  was,  however,  neither 
history  nor  sign  of  lesion  in  any  central  structure,  and  the  whole 
condition  was  regarded  as  one  of  neurotic  disturbance,  which 
might  be  very  much  controlled  if  the  patient  would  only  choose 
to  exert  his  will.  This  view  of  the  nature  of  the  case  received 
strong  support  from  his  previous  history.  He  had  been  in  a 
railway  collision  twelve  years  before.  He  then  received  no 
bodily  injury,  but  he  was  very  nervous  about  himself,  and  four 
months  afterwards  began  to  sufifer  from  spasmodic  wry-neck, 
which  lasted  for  four  months,  and  which  recurred  again  for  a 
short  time  after  an  interval  of  two  years. 

There  was  no  reason  in  this  case  to  attribute  any  want  of 
hona  fides  to  the  man  in  the  presentation  of  his  symptoms, 
although  the  largeness  of  his  claim  and  the  sequel  of  his  case 
would  rather  tend  to  throw  doubt  upon  its  perfect  genuineness. 
When  compensation  was  settled  he  very  speedily  lost  all  the 
spasms  and  returned  to  work,  and  it  was  even  said  by  one  who 
had  taken  a  friendly  interest  in  his  case  that  he  had  recovered 
with  indecent  haste.  But  his  recovery,  in  my  judgment,  was 
due  rather  to  the  fact  that  settlement  of  his  claim  enabled  him 
to  make  the  requisite  effort  to  do  some  work,  and  that  healthy 
occupation  provided  the  means  of  diverting  his  attention  from 
himself  and  his  ailments,  so  that  the  spasms  were  unconsciously 
forgotten  and  forthwith  disappeared.  Five  years  after  the  acci- 
dent the  report  ran  that  he  was  in  good  health,  although  he  had 
been  shaky  and  nervous  for  some  considerable  time  after  his 
claim  was  settled. 

Both  these  cases  present  examples  of  undoubted  predisposition 
to  neurotic  disturbance.  It  is  impossible  to  say  why  the  dis- 
orders should  have  assumed  the  forms  they  did,  but  it  is  inter- 
esting to  note  that  in  both  of  tliem  there  was  a  genuine  dread  of 
spinal  injury,  and  that  in  the  second  case  the  wry-neck  after  the 
former  accident,  and  the  chorea-like  movements  of  the  arm  and 
head,  after  an  interval  of  no  less  than  twelve  years,  were  dis- 
turbances of  the  same  kind.  The  cases,  moreover,  show  of  how 
much  importance  it  is  to  know  something  of  the  previous  history 
of  the  patients,  and  their  special  liabilities  to  disease,  in  order  to 
arrive  at  a  correct  diagnosis. 


3.  Case  i  9. — Shock  to  nervous  system — Hysterical  seizures  "begin- 
ning in  syncope. — K.  C,  aged  thirty -nine,  an  officer  in  the  army, 


82  RAILWAY    INJURIES. 

Hysterical  was  in  rather  a  severe  collision  at  night.  He  was  awake  at  the 
suggested  time,  and  was  thrown  backwards  and  forwards  in  the  carriage, 
by  syncope,  jjg  j^g^(j  j^q  knowledge  of  being  hurt,  and  helped  the  stoker,  who 
was  much  injured.  He  then  finished  his  journey,  the  "  excite- 
ment," as  he  supposed,  "  keeping  him  up."  The  next  morning 
he  felt  very  ill  and  vomited,  and  he  soon  began  to  suffer  from 
pain  across  the  loins,  queer  sensations  all  over  the  body,  nausea, 
giddiness,  and  want  of  sleep.  On  the  third  day  he  took  a  long 
journey  of  several  hundred  miles  to  be  with  some  friends ;  and 
on  the  twelfth  day  after  the  accident  he  suddenly  fell  and  struck 
his  nose  against  the  corner  of  a  table.  He  soon  became  con- 
scious and  screamed  violently.  To  use  his  own  words  :  "  The  fit 
came  on  about  three  in  the  afternoon ;  I  fell  down  and  screamed, 
and  then  began  to  cry  and  sob  violently.  During  it  I  was  un- 
conscious, although  I  knew  that  people  were  around  me,  and  that 
I  must  use  all  my  efforts  to  restrain  myself  and  to  keep  quiet. 
When  all  was  over,  I  did  not  know  what  had  happened."  He 
called  this  fit  an  "hysterical  attack,"  and  the  doctor  who  saw 
him  immediately  afterwards,  and  who  found  him  more  or  less 
unconscious,  thought  that  this  was  its  nature.  Six  weeks  after 
the  accident  he  complained  of  pain  in  the  back,  loss  of  memory, 
inability  to  apply  himself,  occasional  giddiness,  nausea,  and  want 
of  sleep.  He  looked  anxious  and  worn,  and  his  doctor,  who  had 
known  him  for  some  time,  said  that  he  was  undoubtedly  much 
changed  in  manner  and  appearance.  He  had  lost  flesh,  but  all 
the  bodily  functions  were  natural.  He  described  the  fit  in  the 
words  which  have  been  given,  and  said  that  he  had  had  two  or 
three  since,  though  not  so  violent  as  the  first.  A  few  minutes  after 
this  I  had  the  opportunity  of  seeing  him  in  a  fit.  It  had  begun 
with  screaming,  and  he  was  found  l}^ng  on  the  sofa  with  his 
eyes  closed,  his  face  very  pale,  and  a  small  pulse.  He  took  no 
notice  of  my  entry  into  the  room,  but  occasionally  sighed.  Asked 
how  he  was,  he  opened  his  eyes  and  looked  wildly  about.  He 
was  then  very  sick.  After  vomiting  he  roused  himself,  asked 
how  long  I  had  been  there,  and  said  he  was  better.  Before 
leaving  him  he  was  aj)parently  asleep.  Within  the  next  two 
months  he  had  three  or  four  attacks  of  the  same  kind,  though 
of  gradually  lessening  severity.  His  claim  was  settled  six  months 
after  the  accident.  Twelve  months  afterwards  he  still  suffered 
in  a  slight  degree  from  the  effects  of  the  injury,  but  it  did  not 
prevent  him  from  attending  to  his  work.  No  later  record  than 
this  can  be  obtained,  that  six  years  after  the  accident  he  was 
still  on  active  duty.      It  has  some  bearing  on  the  history  that 


THE    FRIGHT    NEUROSES.  83 

this  patient  wrote  repeated,  and  what  might  almost  be  called 
"  hysterical,"  letters  about  his  condition  and  future  prospects, 
and  that  he  made  an  enormous  claim,  thrice  the  amount  which 
he  ultimately  received,  without  resort  to  litigation. 

Nothing  is  known  of  this  patient's  previous  history,  other  than 
that  he  had  always  enjoyed  good  health  ;  and  it  is  worth  asking, 
what  was  the  origin  of  these  hysterical  seizures  ?  It  seems  to 
me  that  in  all  probability  they  began  with  syncope,  which  was 
a  direct  result  of  weakened  cardiac  power  from  the  nervous 
shock,  and  that  they  assumed  the  form  they  did  from  the  very 
fact  that  the  accident  had  produced  a  profound  impression  on  the 
patient's  mind.  He  was  reduced  to  a  condition  in  which  he  was 
ready  to  be  alarmed,  and  when,  after  the  fainting,  he  became 
partially  conscious  upon  the  floor,  he  screamed  hysterically  in 
very  natural  and  increased  fear.  And  each  subsequent  fit  began 
in  the  same  way,  by  a  sensation  of  syncope — not  perhaps  amount- 
ing to  actual  fainting — which  by  the  alarm  it  caused  him  at  once 
determined  the  screaming  and  sobbing  which  were  characteristic 
signs  of  each  attack.  With  returning  strength  and  cardiac  tone 
the  seizures  lessened  in  frequency  and  severity,  until  they  came 
to  an  end.  In  other  words,  the  sensations  induced  by  syncope 
provided  a  suitable  and  adequate  "  suggestion "  for  the  attacks 
from  which  this  man  suffered.  Just  as  a  blow  on  the  shoulder 
may  cause  sensations  which  provide  the  suggestion  for  palsy  of 
motion  or  sensation  in  the  affected  arm,  so  in  disturbances  which 
are  apparently  more  purely  psychical  in  character,  there  is  need 
of  some  suggestion  which  shall  determine  the  particular  disorder 
manifested  in  any  given  case. 


4.  A    like   explanation  seems  to   me   to  account   for  such  a  Vomiting 
symptom  as  continued  vomiting,  the  origin  of  which  is  otlierwise  gestion!"^' 
obscure,  and  which  may  be  erroneously  regarded  as  due  to  some 
grave  central  or  other  disease. 

Case  20. — Nervous  shock — Continued  vomiting. — A  healthy 
woman,  aged  twenty-nine,  the  mother  of  one  child,  was  in  a  very 
slight  collision  in  shunting.  She  was  thrown  suddenly  forwards, 
and  a  box  fell  from  the  rack  and  inflicted  a  minute  punctured 
wound  on  the  left  frontal  eminence.  Until  she  felt  the  blood 
trickling  on  her  forehead  she  did  not  know  she  had  been  hurt. 
An  hour  and  a  half  after  the  accident,  when  she  arrived  at  home, 
she   vomited,   and   from    that   time   onward    vomiting    followed 


84  RAILWAY   INJURIES. 

immediately  upon  each  attempt  to  take  food.  Never  at  any 
time  was  there  the  smallest  indication  of  injury  about  the 
stomach.  Four  days  after  the  accident  she  had  an  attack  of 
acute  hysterical  laughter  and  crying,  and  in  the  course  of  the 
next  four  weeks  attacks  of  a  like  character  were  repeated  several 
times.  She  complained  of  shooting  pains  in  the  neck  and  head, 
and  of  pain,  hypersesthesia,  and  tenderness  over  the  dorsal  region 
of  the  spine.  Nevertheless  there  was  no  spinal  rigidity,  nor  any 
difficulty  in  mo^dng  her  limbs.  Wlien  I  saw  her  a  month  after 
the  accident,  no  evidence  of  local  injury  was  anywhere  discover- 
able, but  her  pupils  were  sluggish  and  wide,  the  knee-jerks  were 
decidedly  exaggerated,  and  there  was  well-marked  though  not 
sustained  ankle  clones,  such  as  is  frequently  seen  in  similar  cases 
of  so-called  functional  neurosis.  The  vomiting  was  still  going  on, 
but  without  pain,  and  with  a  perfectly  clean  tongue.  All  this 
time  she  had  been  in  bed,  and  had  become  extremely  weak. 
There  was  no  rise  of  temperature.  A  new  line  of  treatment  was 
now  begun,  the  object  of  it  being  to  improve  the  nutrition,  by 
often  repeated  small  quantities  of  milk  or  other  light  food  ;  and  if 
possible,  by  the  smallness  of  the  amount  taken  at  a  time,  to 
baulk  the  vomiting  habit.  The  lapse  of  another  month  saw  a 
considerable  improvement  in  her  nutrition,  she  was  able  to  be 
up  and  out  of  doors,  the  pupils  were  smaller,  the  knee-jerks  were 
within  the  normal  range,  and  the  ankle  clones  had  entirely  dis- 
appeared. There  was  not,  however,  any  great  improvement  in 
the  vomiting,  for  an  endeavour  to  take  an  ordinary  meal  im- 
mediately made  her  sick.  The  reason  for  this  was  not  far 
to  seek.  The  patient  had  now  become  an  object  of  special 
sympathy  in  the  village,  and  her  only  return  for  the  bounty  of 
her  neighbours,  both  rich  and  poor,  was  to  go  on  vomiting.  One 
thing  was  now  essentially  called  for  in  order  to  bring  about  her 
recovery,  and  that  was  isolation  from  her  friends.  Accordingly 
she  left  home,  was  placed  in  the  charge  of  a  nurse,  and  treat- 
ment suitable  for  her  condition  was  forthwith  begun.  It  would 
be  untrue  to  say  that  she  never  vomited  again,  because  in  the 
course  of  the  next  three  months  she  did  vomit  twice,  and  twice 
only,  in  the  old  purposeless  way ;  but  this  may  be  said,  that  her 
convalescence  began  from  this  time,  and  that  she  ultimately,  within 
nine  months  of  the  accident,  was  quite  well. 

This  case  is,  to  my  mind,  a  very  instructive  one.  Almost 
uninjured  at  the  time  of  the  accident,  it  is  certain  that  there 
must  have  been  an  amount  of  shock  sufficient  to  cause  the 
vomiting  within  an  hour  and  a  half,  and  the   psychical  effect 


THE    FRIGHT   NEUROSES.  85 

was  indicated  by  an  outbreak  of  acute  hysteria  on  the  fourth 
day.  The  reahty  of  the  nervous  disturbance  was  shown,  more- 
over, by  the  increase  of  the  knee-jerks  and  by  the  ankle  clones ; 
and  a  vicious  circle  was  quickly  established — mal-nutrition  affect- 
ing the  nervous  centres  alike  of  brain  and  cord,  whose  condition  in 
turn  made  the  act  of  vomiting  more  easy  and  more  durable  in  the 
absence  of  some  physical  cause.  There  never  was  any  question 
as  to  the  nature  of  the  case,  and  it  seems  to  me  that  there  can 
be  as  little  doubt  as  to  the  origin  of  that  one  symptom  which 
was  its  especial  feature.  The  initial  act  of  vomiting  gave  the 
suggestion  for  its  continuance  to  a  sensorium  profoundly  affected 
by  the  circumstances  of  the  accident.  And  it  is  abundantly 
obvious  how  a  recognition  of  this  sequence  of  events  was  essential 
for  the  adoption  of  the  line  of  treatment  which  speedily  ended 
in  cure.  Had  this  patient  stayed  at  home,  and  been  treated  on 
the  supposition  that  she  had  some  serious  organic  disease,  the 
result  would  surely  have  been  different.  I  have  now  had  under 
occasional  observation  during  the  past  eight  years  the  case  of  a 
young  man  whose  symptoms  were  not  unlike  those  of  this  woman. 
He  had  been  very  severely  shaken  in  a  collision,  and  there  was 
much  shock,  out  of  all  proportion  to  the  physical  injuries  sus- 
tained. Vomiting  came  on  within  twenty-four  hours,  and  has 
continued  ever  since  in  varying  degrees.  Eepeated  examina- 
tions have  failed  to  discover  any  organic  cause  for  it  either  in  the 
stomach  itself,  the  peritoneum,  or  the  nervous  centres,  disease 
in  one  or  other  of  which  would  in  all  probability  have  shown 
itself  in  this  length  of  time.  By  a  process  of  exclusion,  there- 
fore, the  diagnosis  points  in  the  direction  of  the  last  case,  but 
neither  his  own  medical  attendant  nor  I  have  been  able  to  per- 
suade him  to  submit  to  treatment  by  isolation.  His  case  is  of 
value  as  an  illustration  of  the  fact  that  settlement  of  claim  does 
not  always  work  for  a  patient's  recovery.^ 


5.  We  may  pass  on  now  to  say  something  of  hemianaBsthesia,  HemianEBs- 
surely  one  of  the  most  remarkable  indications  of  cerebral  disorder,  ^g^^ 
The  text-books  of  medicine  and  of  nervous  diseases  contain  such 
full  accounts  of  this  strange  condition,  of  its  many  vagaries  and  its 

^  In  Dr.  Bristowe's  Diseases  of  the  Nervous  System,  p.  40,  is  an  interesting 
lecture  on  "The  Functional  Vomiting  of  Hysteria,"  in  which  he  relates  a  case  of 
vomiting  which  lasted  between  two  and  three  years,  and  which  dated  from  a  voyage 
made  across  the  Atlantic.  The  author  doubts  whether  food  ever  reached  the 
stomach,  and  whether  there  was  not  some  functional  affection  of  the  oesophagus. 


86  RAILWAY    INJURIES. 

accompanying  disorders  of  the  special  senses,  that  there  is  no  call 
to  describe  it  here,  and  I  shall  content  myself  with  a  few  remarks 
upon  particular  cases,  choosing  those  of  men  for  consideration. 

Case  2  i . — Hemiancesthesia  and  hemiparesis,  follovring  hypnotic 
state  from  fright. — A  highly  neurotic  but  otherwise  healthy  man, 
aged  forty-seven,  was  bruised  in  several  places,  head,  neck,  and 
buttocks,  by  being  thrown  suddenly  backwards  and  forwards  in  a 
railway  collision  of  no  great  severity.  He  instantly  lost  conscious- 
ness, and  so  remained  for  two  hours.  On  arrival  at  home  his 
doctor  was  sent  for  immediately,  and  found  him  suffering  from 
left  hemiplegia  in  addition  to  great  emotional  disturbance,  crying 
and  sobbing.  No  examination  was  then  made  as  to  sensation, 
but  two  days  afterwards  he  was  found  completely  anaesthetic  on 
the  same  side,  and  all  the  corresponding  special  senses,  hearing, 
taste,  sight,  and  smell,  were  likewise  affected.  There  was  also 
loss  of  muscular  sense,  impairment  of  the  sense  of  colour,  and 
spasmodic  deviation  of  the  tongue.  The  knee-jerks  were  increased, 
and  there  was  slight  ankle  clonos.  When  I  saw  him  three  months 
afterwards  the  various  symptoms  were  much  diminished  in  degree, 
and  there  was  no  longer  any  deviation  of  the  tongue.  Though 
able  to  walk  and  even  get  downstairs,  his  gait  when  under  ob- 
servation was  singularly  slow  and  laboured  because  of  inability 
to  use  the  left  leg,  the  movements  of  which  were  now  made  in  one 
way  and  now  in  another,  there  being  nothing  specially  charac- 
teristic about  them.  The  whole  muscular  system  was  extremely 
Habby,  but  there  was  no  wasting  of  one  part  more  than  another. 
The  man's  aspect  was  suggestive  of  great  mental  depression,  but  he 
acknowledged  that  he  was  somewhat  better  than  he  had  been.  He 
has  gone  on  improving,  but  it  is  impossible  yet  to  give  a  com- 
plete history.  The  case  is  nevertheless  worthy  of  note  as  it  stands 
because  of  the  early  onset  of  the  symptoms,  and  from  the  fact  of 
the  man  having  immediately  passed  into  that  state  of  daze  or  un- 
consciousness which  seems  to  be  so  important  a  factor  in  their 
development.  There  is  no  reason  to  think  that  his  unconsciousness 
was  the  unconsciousness  of  true  brain  concussion,  for  there  was 
no  local  blow  sufficient  to  determine  a  state  of  coma  of  two  hours' 
duration,  and  the  condition  was  more  probably  that  which  is  due 
to  fright  alone.  Why  in  this  particular  case  the  so-called  functional 
disturbance  should  have  shown  itself  in  hemiplegia  and  hemiansBs- 
thesia  it  is  impossible  to  say,  just  as  no  reason  can  yet  be  given  for 
hemianeesthesia  being  more  common  on  the  left  side  than  on  the 
right.      The  loss  of  sensation   was   in    all  probability   as  early  a 


THE    FRIGHT    NEUROSES.  8/ 

phenomenon  as  the  loss  of  motor  power,  both  ensuing  upon  the 
hypnotic  state  which  was  an  immediate  effect  of  the  accident.  In 
another  case  the  hemiansesthesia  was  detected  on  the  day  after 
the  accident. 

Case  22. — He^niancesthesia,  &c.  &c. — A  man,  aged  forty-three, 
of  neurotic  temperament,  was  in  a  very  trifling  collision,  which 
jolted  him,  however,  from  his  seat  and  deposited  him  on  the 
floor  of  the  carriage.  There  he  found  himself,  and  was  subse- 
quently unable  to  give  any  better  or  more  explicit  account  of 
what  happened  to  him.  There  was  no  evidence,  however,  of  his 
having  been  hurt  bodily,  and  he  went  to  his  business  next  day. 
He  soon  broke  down  completely,  and  a  doctor  who  was  sent  for 
found  him  in  a  semi-dazed  condition,  and  proceeded  immediately 
to  examine  the  state  of  cutaneous  sensation.  It  was  absent  on 
the  whole  right  side,  and  was  accompanied,  as  in  the  last  case,  by 
some  loss  of  power  in  the  right  leg.  There  were  also  present  in 
an  extreme  degree  the  usual  affection  of  the  special  senses,  loss 
of  muscular  sense,  and  spasm  of  the  tongue.  With  it  also  were 
many  neurasthenical  symptoms,  coldness  of  the  limbs,  especially  of 
the  right  leg,  occipital  headache,  loss  of  sexual  desire,  and  widely 
dilated  pupils.  Occasionally  also  he  had  hystero-epileptic  seizures. 
For  many  months  there  was  little  or  no  improvement,  and  at  the 
end  of  a  year,  during  which  he  had  led  the  life  of  an  invalid,  and 
made  no  attempt  to  work,  the  hemiansesthesia  still  continued. 
His  claim  was  finally  settled,  but  whether  that  put  an  end  to 
the  anaesthesia  or  not  I  am  unable  to  say.  I  think,  however,  it  is 
highly  probable,  for  it  put  an  end  to  the  "  suggestion  "  of  it  in 
frequent  medical  examinations ;  and  this  is  certain,  that  the  man 
very  soon  resumed  his  ordinary  mode  of  life,  and  within  nine 
months  gave  every  indication  that  his  bodily  health  had  been 
restored. 

I  do  not  for  one  moment  wish  to  convey  the  impression  that 
this  case  was  not  a  perfectly  genuine  one.  There  was,  of  course, 
no  doubt  as  to  the  existence  of  the  hemiansesthesia  and  the 
accompanying  phenomena,  but  from  beginning  to  end  of  its 
long  history  it  was  an  example  of  the  injurious  influence  which 
the  matter  of  compensation,  and  dawdling  about  at  home,  have 
in  cases  of  the  kind.  Hemi-  or  any  other  distribution  of 
anaesthesia  is  a  valuable  indication  of  the  nature  of  any  given 
case.  It  is  an  expression  of  an  abnormal  cerebral  condition,  and, 
whatever  may  have  been  its  origin  and  exciting  cause,  there 
cannot  be  anything  much  worse  for  a  patient  than  to  have  the 


88  RAILWAY   INJURIES. 

symptom,  if  not  revived,  at  any  rate  kept  alive,  by  repeated 
examinations,  which  are  made  either  from  genuine  interest  in 
the  case,  or  in  preparation  for  an  action  at  law.  I  have  pointed 
out  on  an  earlier  page  how  movements  which  fail  from  failure  of 
the  will  to  make  them  may,  nevertheless,  be  automatically  per- 
formed. The  concej)tion  of  something  of  the  same  kind  is  much 
more  difficult  in  the  case  of  sensory  than  it  is  in  the  case  of  motor 
power,  but  one  could  hardly  go  as  far  as  to  say  that  it  was  im- 
possible for  common  sensation  to  be  within  the  range  and  influ- 
ence of  what  is  termed  Will.  The  receptivity  of  the  sensorium 
for  impressions  which  reach  it  from  the  periphery  may  likewise 
be  both  voluntary  and  automatic ;  and  the  history  of  some  cases 
inclines  me  to  think  that  a  person  may  acquire  the  power  of 
inducing  anaesthesia,  much  in  the  same  way  as  by  practice  he 
may  induce  the  repetition  of  motor  phenomena  which  are  close 
imitations  of  real  disease.  At  all  events  I  do  not  think  that 
hemiansesthesia,  real  in  itself  though  it  be,  can  be  regarded  as 
outside  the  category  of  those  cases  to  which  the  following  c^uota- 
tion  from  Dr.  Wilks  is  more  or  less  apphcable : — "  I  do  not  look 
on  hysteria,"  he  says,  "  as  a  fictitious  disease  or  a  sham ;  the 
condition  with  all  the  phenomena  is  real  enough ;  at  the  same 
time  the  hysterical  state  is  so  often  associated  with  some  moral 
obliquity  that  it  is  very  difficult  to  say  how  far  a  particular 
symptom  is  feigned  or  exaggerated "  ("  Diseases  of  the  Nervous 
System,"  p.  55,  2nd  edition).  He  records  a  case  of  gross  im- 
posture, in  the  history  of  which  a  pilgrimage  to  Lourdes  played 
a  conspicuous  part,  hemiansesthesia  being  amongst  the  man's 
symptoms. 


The  moral       6.   It  would  be  wroug  and  most  unjust  to  say  or  to  suggest 

iiemianEes-  that  moral  obliquity  is  an  attribute  of  all  persons  who  present 

theaia.        hysterical  symptoms,  yet,  even  where  there  is  a  condition  such  as 

hemiancesthesia,  the  possibility  of  a  certain  amount  of  conscious 

influence  over  the  chief  symptom  must  be  borne  in  mind. 

Case  23. — Hcmiancesthesia,  &c. — Doubts  of  perfect  genuineness. — • 
A  man,  aged  fifty -one,  was  in  an  altogether  trivial  accident,  in 
which,  if  he  was  injured  at  all,  he  sustained  a  slight  sprain  of 
his  posterior  cervical  muscles.  He  did  not  know  he  had  been 
hurt  until  the  night  after  the  accident,  when  he  woke  with  a 
start,  and  the  next  morning  he  felt  shaky  and  nervous,  and  was 
unable  to  write  a  letter.     He  took  to  his  bed,  and  after  he  had 


THE    FRIGHT   NEUROSES.  89 

been  there  for  a  week  he  was  examined  by  a  surgeon,  who 
observed  such  inconsistencies  in  his  statements  and  symptoms  as 
to  lead  him  to  regard  the  case  as  not  perfectly  genuine.  When 
I  saw  him  myself  a  month  afterwards  there  was  left  hemianais- 
thesia,  and  some  weakness  in  motor  power  also.  There  were 
spasms  during  examination  of  the  shoulder  and  neck  muscles  of 
the  left  side,  and  certain  movements,  such  as  squeezing  with  the 
left  hand  and  putting  out  the  tongue,  he  professed  himself  unable 
to  perform,  although  neither  in  his  speech,  nor  in  ordinary 
movements  of  the  limb  automatically  performed,  was  there  any 
sign  of  paralysis.  The  special  senses  were  also  affected  in  the 
usual  way.  After  an  interval  of  two  months  there  was  slight,  but 
only  slight,  improvement.  How  long  this  state  of  things  lasted 
it  is  impossible  to  say,  because  renewed  requests  that  the  man 
might  be  seen  by  surgeons  for  the  railway  company  were  refused 
on  the  ground  that  he  was  far  too  ill  to  allow  of  any  examina- 
tion. An  exorbitant  claim  was  presented,  and  the  case  went  to 
trial.  It  was  then  conclusively  proved  that  during  most  of  the 
time  when  he  was  too  ill  to  be  examined,  and  was  wholly  unfit 
for  anything  except  confinement  to  bed,  he  was  deceiving  his 
own  doctor,  and  was  leading  a  life  of  very  considerable  enjoy- 
ment— after  dark.  In  fact  he  loved  darkness  rather  than  light. 
No  good  purpose  can  be  served  by  giving  in  detail  all  the  facts  of 
this  case — let  them  be  recorded  by  his  own  advisers,  legal  and 
medical ;  but  this  may  be  said  about  it,  that  the  accompanying 
exaggeration  and  imposture  were  such  as  to  throw  very  grave 
suspicion  on  the  perfect  genuineness,  not  on  the  perfect  reality,  of 
the  symptom  hemianaesthesia.  And  in  endeavouring  to  come  to  a 
right  conclusion  as  to  the  value  of  this  symptom  in  any  given  case 
there  is  an  error,  I  feel  sure,  to  be  avoided  in  looking  upon  henii- 
angesthesia  as  a  thing  which  stamps  a  case  at  once  as  genuine 
simply  because  we  cannot  say  how  it  is  induced.     Experto  crede. 


7.  The   record  of    two   cases   will   now    be   given   where    the  Hypnotic 
hypnotic  condition  was  even  more  marked  than  in  any  which  [^  men.^^ 
have   preceded.      In  both  the   patients   there  was  a   history  of 
previous  psychical  disturbance,  and  there  was  insanity,  moreover, 
in  their  families.      Both,  I  believe,  were  predisposed  to   suffer 
from  neurotic  disorders  should  any  adequate  cause  arise. 

Case   24. — Hypnotic  catalepsy,  &c. — B.  A.  B.,  aged  thirty-six, 
a  strong  and  active  man,  was  in  a  railway  collision  at  night,  in 


90  RAILWAY   INJURIES. 

which  a  large  number  of  persons  were  more  or  less  injured, 
though  the  accident  was  not  severe.  He  complained  shortly 
afterwards  of  having  been  shaken,  and  also  that  his  back  had 
received  a  wrench,  owing,  he  thought,  to  his  sitting  sideways 
when  the  collision  occurred.  He  had  one  or  two  slight  bruises 
on  one  arm,  and  a  sprain  of  one  wrist.  For  the  first  few  weeks 
after  the  accident  there  were  no  symptoms  of  constitutional 
disturbance  or  of  serious  injury,  but  the  man  said  that  he  could 
not  hold  himself  upright  or  walk  any  distance  in  consequence  of 
tlie  injury  to  his  back,  and  the  doctors  who  saw  him  thought 
that  he  was  to  some  extent  exaggerating  the  effects  of  his  injuries. 
About  five  weeks  after  the  accident  he  suddenly  changed.  He 
constantly  repeated  that  he  was  going  mad,  and  that  he  was  sure 
he  was  going  to  be  paralysed.  He  began  at  the  same  time  to 
take  violent  exercise,  walking  several  miles  a  day  at  great  speed. 
This  was  followed  by  great  exhaustion,  during  which  he  was 
"  wandering  and  hysterical,"  and  there  ensued  attacks  which  were 
described  by  a  medical  man  who  saw  him  as  "  hysterical  mania." 
These  continued  for  several  days.  The  state  which  followed  next 
can  only  be  described  in  the  words  recorded  at  the  time.  "  He  is 
lying  in  bed  on  his  right  side  with  his  knees  drawn  up.  There  is 
not  the  slightest  movement  when  he  is  spoken  to,  or  when  he  is 
touched  through  the  bed-clothes.  There  is  a  continuous  quivering 
of  the  upper  eyelids.  Asked  to  put  out  his  tongue,  there  is  no  re- 
sponse, though  when  the  lips  are  pulled  apart  he  seems  to  make  some 
effort  to  open  the  jaws  and  protrude  the  tip.  By  raising  the  lids 
the  pupils  are  seen  to  be  equal  in  size,  and  they  react  normally 
to  light.  The  aspect  of  his  face  is  that  of  complete  repose  and 
disregard,  but  he  is  obviously  not  entirely  unconscious.  Pulse 
56.  His  arms  and  hands  remain  in  any  position  in  which  they 
are  placed.  The  arms  and  legs  are  very  much  wasted,  and  the 
whole  body  seems  emaciated.  The  legs  are  at  once  drawn  up 
spasmodically  on  tickling  the  soles,  and  pinching  the  calves  evi- 
dently causes  pain,  for  he  groans  and  much  contorts  his  face. 
On  touching  any  part  of  the  chest  or  abdomen  rather  firmly  with 
the  fingers,  the  whole  body,  face,  and  arms  are  spasmodically 
worked,  the  legs  being  frequently  abducted  and  adducted.  The 
abdominal  muscles  are  almost  as  hard  as  a  board."  He  is  said 
to  have  occasionally  an  "hysterical  fit,"  consisting  of  spasms  all 
over  the  body,  beginning  with  an  expression  of  fright,  and  lasting 
about  fifteen  minutes.  An  experienced  nurse  attending  him  says 
they  are  not  like  epileptic  fits.  He  takes  plenty  of  nourishment, 
milk  and  beef-tea,  but  little  or  no  alcohol.      He  passes   water 


THE    FRIGHT   NEUROSES.  pi 

only  once  within  twenty-four  hours,  sometimes  groaning  before- 
hand as  if  in  sign  to  the  nurse.  The  bowels  are  never  moved 
without  enema.  He  lies  for  hours  absolutely  motionless,  and 
three  weeks  ago  he  never  moved  a  finger  for  a  whole  day,  nor 
passed  water  once.  A  serious  feature  in  the  case  is  the  great 
wasting,  food,  although  taken  in  abundance,  seeming  to  have  small 
influence  in  maintaining  the  bodily  nutrition,  and  he  looks  as  if 
he  might  sink  and  die.  This  condition  lasted  for  about  six 
weeks,  and  then  under  the  influence  apparently  of  larger  doses 
of  alcohol — the  increasing  exhaustion  and  wasting  having  seemed 
imperatively  to  call  for  it — he  began  to  emerge  from  the  state 
in  which  he  was,  to  move  in  bed,  to  open  his  eyes,  to  take  more 
solid  food,  and  even  to  speak  a  little  very  feebly.  He  was  soon 
able  to  get  up  and  go  about,  made  flesh  again  rapidly,  and  took 
some  exercise.  He  was,  however,  very  nervous  and  apprehensive, 
and  felt  sure  he  should  never  get  well.  Seven  months  after  the 
accident  he  still  complained  of  his  back,  and  held  himself  in  a 
stooping  posture.  Questions  were  answered  very  slowly,  and  any 
required  act,  such  as  that  of  putting  out  the  tongue,  seemed  to 
demand  an  unnatural  effort.  From  this  time  he  continued  to 
improve,  and  in  eight  months  he  was  so  far  well  that  it  was 
thought  right  and  prudent  to  allow  him  to  arrange  his  com- 
pensation. 

It  bears  upon  the  case  that  the  claim  was  by  no  means  large, 
and  there  was  no  reason  at  any  time  to  beheve  that  the  matter 
of  compensation  was  unduly  affecting  the  patient's  mind.  Of 
far  greater  importance  is  the  fact  that  there  was  a  strong  family 
history  of  insanity.  His  father  and  one  uncle  were  "  queer,"  a 
brother  had  actually  been  in  an  asylum,  and  his  sister  is  very 
hysterical.  His  own  account  of  the  condition  in  which  he  lay 
so  long  is,  "  that  he  knew  all  that  was  going  on  around  him,  that 
he  remembered  when  the  doctors  came,  and  knew  always  when 
there  were  more  of  them  than  usual,  but  that  he  could  not  speak, 
and  supposed  that  his  brain  would  not  direct  him  to  do  so." 
The  sequel  of  the  case  is  satisfactory,  the  following  report  of 
him  being  obtained  two  years  after  his  claim  was  settled,  or 
thirty-three  months  after  the  accident : — "  His  recovery  was 
gradual,  but  without  any  relapses.  He  married  six  months  after 
his  claim  was  settled,  and  has  one  son  about  two  months  old. 
He  has  had  no  illnesses,  is  at  present  strong  and  stout,  and  is 
emigrating  some  time  this  month." 

It  is  impossible  to  conceive  that  the  symptoms  in  a  case  like 
this  could  have  been  in  any  way  dependent  upon  injury  to  the 


92  RAILWAY    INJURIES. 

spine,  and  this  much  may  be  said  of  it,  that,  when  this  strange 
condition  supervened,  all  thought  of  injury  to  the  spine  as  a  cause 
thereof  passed  from  the  minds  of  those  who  were  attending  him. 
The  man,  indeed,  himself  had  shown,  by  the  violent  bodily  exer- 
cise which  ushered  in  the  mental  disturbance,  that  there  really 
was  no  sign  of  paralysis  or  even  weakness  in  the  legs,  and  that 
the  pain  in  the  back  was  very  slight  indeed.  The  condition  was 
essentially  one  of  profound  mental  disturbance  originated  by 
shock,  immediate  fright,  and  the  fear  of  impending  evil,  in  a 
man  with  a  strong  family  taint  of  insanity.  The  higher  cerebral 
faculties  seemed  for  the  time  to  be  in  that  state  of  slumber 
which  has  been  mentioned,  and  his  general  condition  was  very 
like  that  described  by  Heidenhain  ^  and  others  as  occurring  in 
the  so-called  mesmeric  or  hypnotic  state,  and  associated  with 
cataleptic  phenomena. 

Case  25. — Hypnotic  Catalepsy — Delusions. — Almost  exactly 
parallel  with  the  last  case  is  that  of  a  strong  and  healthy  man,  aged 
thirty,  who  was  in  a  collision,  and  who  presented  the  usual  signs 
of  having  received  a  sprain  of  his  back  and  some  general  sliock 
to  his  nervous  system.  He  lay  for  long  in  much  the  same  hypnotic 
state  as  the  last  patient,  alternating  with  fits  of  violence  and  passion. 
When  he  awoke  from  this,  he  became  the  subject  of  a  delusion 
that  he  was  being  poisoned,  and  was  accordingly  removed  to 
an  asylum,  about  ten  months  after  the  accident.  He  remained 
there  six  weeks ;  and  while  an  inmate  he  adopted  a  peculiar 
gait,  which  lasted  up  to  the  time  when  his  claim  was  settled, 
two  years  after  the  accident,  and  which  formed  the  ground 
of  a  very  serious  view  that  he  had  received  a  permanent  damage 
to  his  spinal  cord.  His  mode  of  walking  was  thus  described 
when  he  came  out  of  the  asylum  :  "  He  puts  the  weight  of  his 
body  on  two  sticks  placed  in  advance  of  him,  and  draws  each  leg 
alternately  forward  with  the  foot  much  everted.  When  about  to 
advance  one  leg  he  twists  the  other  inwards  on  the  toes,  so  that 
the  latter  points  forwards  instead  of  outwards.  He  keeps  the 
knees  quite  stiff.  In  this  way  he  shuffles  along  with  great 
rapidity.      As  he  stood  with  his  back  against  the  wall,  he  was 

^  Writing  of  the  disturbances  of  the  motor  apparatus  which  have  been  observed 
during  hypnosis,  he  says  :  "  More  or  less  extensive  cataleptic  rigor  becomes  estab- 
lished ;  the  limbs  thus  affected  remain  in  any  imaginable  position  they  are  placed  in. 
The  will  has,  it  is  true,  not  wholly  lost  influence  over  them,  but  it  is  exerted  with 
very  great  difficulty.  If,  however,  with  a  great  effort,  the  parts  be  set  in  activity, 
there  often  results,  instead  of  simple,  convulsive  movements  which  spread  to  other 
parts  of  the  body." — Op.  cit.,  p.  77. 


THE   FRIGHT   NEUROSES.  93 

asked  to  lift  up  his  knee,  but  he  professed  utter  inabihty  to  do 
so."  Very  careful  examination  was  made  at  this  time  as  to  the 
nutrition  and  state  of  the  legs,  and  a  report  shortly  afterwards 
ran  thus :  "  The  reflex  irritability  and  faradic  excitability  of  the 
muscles  of  the  lower  extremities  are  normal ;  there  is  an  entire 
absence  of  affection  of  the  bladder  or  rectum,  or  of  any  trophic 
change,  such  as  muscular  atrophy  and  bed-sores.  There  is  also 
an  entire  absence  of  muscular  tension,  rigidity,  contraction,  or 
deformity  in  the  lower  limbs.  Examination  did  not  enable  me 
to  determine  whether  any  affection  existed  on  the  sensory  side, 
as  the  patient  absolutely  refused  to  answer  any  questions.  On 
the  whole,  my  opinion  of  the  case  is  that  it  is  an  example  of 
many  recorded  instances,  in  which  a  slight  and  unimportant 
injury  develops  various  emotional  and  hysterical  symptoms."  At 
a  final  visit  made  to  him  before  his  claim  was  settled,  he  com- 
plained more  than  ever  of  pain  in  his  back,  and  called  out  loudly 
when  touched  upon  his  clothes.  While  sitting  in  his  chair  he 
could  move  his  legs  in  any  direction  required  of  him,  though 
much  persuasion  was  necessary  to  get  him  to  move  them  at  all. 
He  suddenly  vomited  without  any  precedent  sign  of  nausea  or 
retching.  Asked  to  walk  across  the  room,  he  essayed  to  do  so 
after  much  persuasion,  and  walked  in  the  manner  already  de- 
scribed. There  was  no  tremor  of  the  legs  during  progression, 
and  nothing  like  ankle-clonus  or  the  gait  which  is  seen  when 
there  is  secondary  degeneration  of  the  cord.  Subsequently,  on 
being  asked  to  go  into  the  next  room,  he  began  to  do  so,  but 
almost  immediately  fell  down  flat  on  the  floor,  whence  he  was 
lifted  and  carried  away.  A  very  large  claim  for  compensation 
was  preferred,  and  was  arranged  two  years  after  the  accident, 
not,  however,  without  a  resort  to  litigation.  He  shortly  after- 
wards left  the  house  in  which  he  had  been  living,  and  for  some 
time  it  was  not  known  where  he  was.  Forty-two  months,  how- 
ever, after  the  accident,  he  was  fortunately  seen  by  one  of  the 
medical  men  who  had  visited  him  during  his  long  illness,  and  he 
found  him  in  perfect  bodily  health  and  vigour,  and  the  father  of 
another  child.  It  should  be  stated,  as  having  an  important  bear- 
ing on  the  case,  that  the  man's  previous  history  was  bad.  He 
was  always  very  irascible,  and  some  years  previous  to  the  acci- 
dent he  had  been  laid  up  with  sunstroke.  There  was  also  some 
doubtful  history  of  insanity  in  his  family. 

It  will  not  be  thought  that  this  case  has  been  mentioned 
unnecessarily,  when  it  is  pointed  out  that  pain  in  the  back  was 
throughout  a  prominent  symptom,  and  that  it  was  considered  by 


94  RAILWAY   INJURIES. 

some  to  be  a  case  of  severe  injury  to  the  spine.  From  the  first 
moment,  indeed,  treatment  was  specially  directed  to  his  vertebral 
column,  and  a  most  careless  examination  of  the  urine,  which  was 
found  to  be  feebly  akaline  after  it  had  been  standing  for  some 
time,  seemed  to  lend  support  to  the  diagnosis  that  there  had 
been  injury  to  the  spinal  cord. 

It  need  cause  no  surprise  that  there  were  wide  differences  of 
opinion  as  to  the  nature  of  this  case.  "  Shamming,"  on  the  one 
hand,  to  sclerosis  of  the  lateral  columns,  preceded  and  originated 
by  a  meningitis,  on  the  other,  formed  the  two  extremes.  The 
truth  lay  between  them,  and  that  opinion  proved  correct  which 
held  that  it  was  essentially  a  case  of  functional  disturbance, 
and  that  as  there  was  no  special  reason  or  symptom  to  place  any 
lesion  in  the  spinal  cord,  the  man  would  in  all  probability  get 
perfectly  well.  The  pre"\dous  history  of  the  patient  showed  that 
he  was  liable  to  serious  psychical  disturbance,  but  it  is  only 
right  to  add  that  the  motive  in  this  case  for  maintaining  the 
neurotic  state  was  exceedingly  strong.  Control  might  have  been 
exercised,  I  believe,  by  this  man  far  more  easily  than  by  the 
previous  patient,  and  the  representation  of  many  of  his  symp- 
toms was  not  very  far  from  being  wilful.  Since  this  case  was 
originally  described  the  man  has  been  in  another  accident,  and 
in  support  of  his  claim  for  compensation  he  again  adopted  the 
peculiar  gait  which  has  been  described.  He  carelessly  forgot, 
however,  to  keep  it  up  on  all  occasions,  and  the  early  settlement 
of  his  claim  was  a  direct  consequence.  As  to  this  particular 
symptom  in  the  case  no  more  need  therefore  be  said.  Some 
parts  of  a  case  may  be  genuine  but  not  all,  nor  does  a  real 
psychical  disturbance  enable  a  man  the  better  to  resist  the 
temptation  to  invent  or  exaggerate  symptoms  in  view  of  a 
pecuniary  claim. 


Three  8.  Glancing  finally  over  the  cases  mentioned  in  this  chapter, 

the  Wght  the  number  of  which  might  have  been  multiplied  almost  in- 
neuroses.  definitely,  it  has  to  be  noted  that  the  physical  severity  of  the 
accident  or  the  bodily  injury  has  obviously  but  little  to  do  with 
the  symptoms  which  supervene.  Nothing  is  more  certain  than 
this,  in  searching  for  a  cause  of  the  symptoms,  that  it  is  not  in 
bodily  injury  that  the  cause  is  to  be  found.  One  man  may  be 
hurt  in  one  way,  another  in  another,  many  are  not  hurt  at  all, 
but  the  symptoms  have  all  a  common  cause,  best  and  most  com- 
prehensively expressed  in   the  one   word — fright.      And  varied 


THE    FRIGHT    NEUROSES.  95 

though  the  symptoms  may  be,  they  are  the  manifestations  of  a 
fright  neurosis.  This  also  is  the  burthen  of  the  teaching  of 
Oppenheim  in  the  work  to  which  reference  has  been  already 
made.  In  his  experience,  however,  and  in  his  view,  psychical 
disturbance  and  change,  amounting  almost  to  insanity,  have  a 
more  prominent  place  in  the  history  of  his  cases  than  has  been 
my  own  experience,  or  is  to  be  met  with  in  tlie  description  of 
cases  in  the  English  tongue.  Thus,  in  one  place  we  find  him 
speaking  of  anxiety  growing  into  a  real  pathological  entity,  and 
of  the  great  majority  of  the  cases  falling  into  a  distinct  cate- 
gory of  traumatic  neuropsychoses.  He  is  satisfied  neither  with 
"  traumatic  hysteria,"  nor  with  "  traumatic  neurasthenia,"  as  suit- 
able terms  to  describe  the  cases  which  he  has  himself  had  under 
observation.  I  do  not,  however,  think  that  "  neuropsychosis  "  is  a 
term  altogether  applicable  to  the  majority  of  the  cases  seen  in 
this  country,  and  I  am  inclined  to  believe  that  there  are  three 
main  types  of  functional  nervous  disorder  following  injury — the 
hysterical,  seen  in  France  ;  the  psychical,  and  more  markedly 
hypochondriacal,  seen  in  Germany ;  and  the  neurasthenical, 
seen  here.  So  much,  however,  depends  on  the  way  in  which 
cases  of  this  kind  are  looked  at,  that  it  would  be  no  surprise  to 
me  were  Oppenheim  to  see  in  a  hundred  English  cases  typical 
examples  of  his  own  neuropsychoses ;  Charcot  in  a  hundred 
German  a  vast  amount  of  hysteria ;  and  an  English  observer 
both  in  French  and  German  cases  many  symptoms  indicative  of 
neurasthenia.  All  are,  I  believe,  describing  the  same  thing,  and 
neurasthenia,  it  must  be  remembered,  is  itself  a  functional 
nervous  disorder  through  and  by  which  many  symptoms  arise. 


9.  At  any  rate,  if  the  cases  described  by  Oppenheim  are  Occasional 
examples  of  the  cases  most  frequently  met  with  in  Germany,  the  orders, 
type  in  that  country  differs,  it  seems  to  me,  from  the  type  in 
this.  Not  that  cases  of  psychical  disorder  are  not  met  with 
here,  but  that  they  are  far  less  common  than  in  that  country. 
In  some  of  the  cases  in  my  own  experience  the  symptoms  have 
been  originated  by  something  more  than  fright,  and  there  has 
been  a  clear  history  of  concussion  of  the  brain,  while  in  others 
the  evidences  of  nerve  prostration  or  general  neurasthenia  have 
been  especially  prominent.  Thorburn  relates  the  case  of  a  woman 
with  left  hemiangesthesia  {op.  cit,  p.  196)  following  severe  shock 
and  bruises  in  the  Hexthorpe  collision,  of  whom  he  writes : — 
"  Her  mental  condition  was  remarkable.       She  had  an  intensely 


g6  RAILWAY   INJURIES. 

frightened  '  scared '  look,  like  that  of  a  wild  animal.  She  paid 
little  or  no  attention  to  her  surroundings,  and  it  was  with  the 
greatest  difficulty  that  she  could  be  got  to  answer  even  simple 
questions.  She  was  quite  incapable  of  connected  speech,  but 
there  were  none  of  the  emotional  manifestations  usually  regarded 
as  hysterical."  A  year  later  this  condition  had  passed  away, 
although  there  was  still  some  impairment  of  sensation.  Com- 
menting on  the  case,  he  says  that  beyond  the  hysterical  hemi- 
ansesthesia,  there  was  for  a  time  a  profound  mental  change  also 
of  hysterical  origin. 

The  same  writer  describes  a  case  of  hysterical  melanchoha  with 
occasional  suicidal  impulses.  The  man,  however,  had  never 
attempted  to  follow  them  out,  and  when  his  claim  was  settled  he 
improved.  In  a  case  quite  recently  under  my  own  observation, 
in  which  there  were  symptoms  of  extreme  neurasthenia,  the 
patient,  a  man  aged  thirty-three,  suffered  for  some  weeks  from  the 
greatest  mental  depression,  had  visions  of  horrible  faces  before 
him  at  night,  and  suicidal  impulses  which  led  him — himself — to 
take  care  that  he  was  never  left  alone.  Thus  protected,  he  never 
made  any  attempt  on  himself,  and  when  his  strength  began  to 
return,  all  thoughts  of  self-destruction  passed  away ;  but  so  over- 
powering was  the  sense  and  the  remembrance  of  his  mental  depres- 
sion that,  weeks  afterwards,  he  said  he  wished  that  he  had  really 
committed  suicide.  This  man  had  been  in  a  very  severe  collision, 
and  was  bruised  in  many  places,  but  it  was  not  until  three  hours 
after  the  accident,  when  he  was  far  from  the  scene  of  it,  that  he 
became  unconscious.  And  on  this  there  ensued  the  symptoms  of 
nerve  prostration,  together  with  slight  hemiansesthesia  of  transient 
duration,  and  the  mental  symptoms  which  have  been  named.  Six 
months  after  the  accident,  when  he  was  begmning  more  rapidly  and 
decidedly  to  improve,  he  still  had  an  expression  of  the  intensest 
anxiety,  as  if  he  had  passed  through  something  very  terrible.  I 
do  not  propose  to  dwell  longer  on  this  class  of  symptoms,  because 
the  type  of  case  to  which  they  belong  is  certainly  not  common  in 
this  country.  The  reader  must  therefore  turn  to  Oppenheim's 
work  for  information  on  the  subject. 

These  symptoms  of  mental  disorder  seem  to  me  to  emphasise 
in  a  special  manner  the  fact  that  most  of  the  results  of  railway 
injury  are  essentially  psychical  in  origin.  Belief  in  their  reality 
is  certainly  not  lessened  by  the  fact  that,  in  Oppenheim's  experi- 
ence, many  of  the  sufferers  were  not  in  a  position  to  claim  com- 
pensation for  the  injuries  they  had  sustained ;  and  at  the  same 
time  it  will  not  be  questioned  that  the  symptoms  of  mental  dis- 


THE    FRIGHT    NEUROSES.  97 

turbance  may  be  readily  increased  and  kept  alive  by  those  very 
things,  which,  in  the  case  of  other  symptoms,  are  so  prone  to  work 
prejudicially  and  to  retard  recovery.  A  very  great  deal  depends 
also  on  the  manner  in  which  the  various  complaints  are  regarded 
and  observed,  and  no  one  will  deny  that  the  creation  and 
development  of  all  sorts  of  symptoms  may  be  readily  induced, 
when  patients  are  in  this  condition,  by  leading  questions  which 
suggest  them  to  their  minds. 


CHAPTER  YI. 

ON    TREATMENT. 

Summary. — l.  The  f^pinal  injuries  :  Treatment  of  sprains  by  rest,  warmth,  movement, 
and  massage. — 2.  Need  of  care  in  cases  of  spinal-joint  or  intraspinal  injury. — 3. 
Neurasthenia,  no  specific  remedy  for  :  The  abuse  of  bromide  of  potassium. — 4. 
Sleeplessness. — 5.  The  bodily  nutrition. — 6.  Hysterical  cases  and  the  need  for 
isolation  :  The  Weir  Mitchell  treatment. — 7.  The  value  of  perfect  rest. 

I  PROPOSE  in  this  chapter  to  make  a  few  collective  remarks  on 
the  principles  which  should  underHe  the  treatment  or  general 
mauascement  of  the  various  cases  which  have  been  considered. 
It  has  been  pointed  out  that  compensation  very  freijuently  exerts 
an  injurious  influence  on  the  clinical  history  of  railway  injuries, 
and  it  may  at  once  be  said  that  were  there  no  Cjuestion  of  com- 
pensation the  treatment  of  them  would  be  decidedly  easier  than 
it  is.  An  endeavour,  however,  must  be  made  as  far  as  possible 
to  keep  this  matter  in  the  background,  and  to  discuss  the  subject 
of  treatment  on  the  assumption  that  our  patients  are  anxiously 
desirous  to  get  well,  and  to  have  the  best  that  can  be  done  for 
them  in  order  to  promote  recovery. 


The  spinal  1.  First  of  all,  as  to  those  spinal  injuries,  which  we  have 
Trea"me"nt  secu,  in  the  great  majority  of  cases,  to  consist  of  sprains  of 
of  sprains    m^igcular  and  ligamentous  structures.      The  two  conditions  which 

by  rest.  " 

warmth,  luivc  to  be  remedied  are  pain  and  stiffness,  and  care  has  of 
and  '  course  to  be  taken  that  no  harm  sliall  ensue  from  the  treatment 
massage,  adopted.  Diagnosis  is,  therefore,  all  important,  and  it  is  essential, 
by  a  very  careful  examination,  to  make  sure  that  the  injury  is  not 
of  a  more  serious  nature  than  usual,  for  the  line  of  treatment 
which  is  necessary  for  the  removal  of  stiffness  would  be  that 
which  above  all  others  is  objectionable  in  the  case  of  osseous 
or  meningeal  injury, 

Eest  and  warmth  are,  in  the  early  stages,  the  two  things  most 
conducive  to  relief  from  spinal  pain ;  rest  by  reclining  in  bed, 

98 


ON    TREATMENT.  99 

warmth  by  the  continuous  application  of  hot  fomentations  or 
poultices.  In  every  case,  the  question  has  to  be  considered, 
"  How  long  ought  a  man  to  stay  in  bed  ? "  and  the  .answer  to 
it  must  very  much  depend  upon  the  severity  of  the  injury,  on 
the  character  of  the  pain,  and  the  extent  of  the  spinal  column 
which  is  involved.  There  are  very  few  instances,  however,  in  which 
the  patient  should  be  longer  than  three  weeks  in  bed,  and  in  many 
it  is  decidedly  advantageous  that  he  should  be  up  much  sooner. 
For  the  longer  he  is  at  rest  upon  his  back, — and  the  rest,  be  it 
remembered,  is  simply  to  allow  time  for  the  complete  resolution 
of  the  subcutaneous  injury  sustained, — the  more  likely  is  it  that 
he  will  suffer  from  spinal  stiftness  afterwards.  This  is  what  we 
are  wont  to  see  in  the  case  of  sprains  in  the  neighbourhood  of 
the  joints  of  the  limbs,  and  there  is  nothing  in  the  case  of  spinal 
sprains  to  exempt  that  part  of  the  body  from  like  consequences. 
The  man  must  be  up  and  move  about ;  and  gentle  gymnastic 
exercise  each  day,  such  as  he  himself  can  make  at  home,  will  do 
much  to  prevent  the  increase  of  spinal  rigidity,  and  to  remove 
that  which  is  already  present.  Here,  however,  comes  in  the 
difficulty,  that  the  pain  which  is  sure  to  follow  the  first  move- 
ments made  will  be  to  his  mind  an  unanswerable  reason  for  not 
moving  any  more.  Compensation  is  likely  to  support  him  in 
this  resolve,  and  all  attempts  to  get  him  to  move  about  are  likely 
to  be  frustrated.  The  stiffness  increases,  and  is  more  incapaci- 
tating, and  it  becomes  essential,  perhaps,  to  adopt  some  more 
definite  and  vigorous  treatment.  Massage,  it  is  well  known,  is 
of  inestimable  value  in  the  treatment  of  sprains  and  other  injuries 
in  the  neighbourhood  of  joints,  and  recently  the  practice  has  been 
advocated  of  treating  sprained  joints,  and  even  fractures  in  the 
neighbourhood  of  joints,  by  immediate  massage  without  a  pre- 
liminary period  of  rest.  The  same  treatment  is  to  be  recom- 
mended for  the  stiffness  of  a  sprained  spine,  but  it  must  be 
systematically  carried  out,  care  being  taken  throughout  that  no 
undue  strain  be  put  upon  the  system  generally,  should  the  bodily 
nutrition  be  below  the  natural  standard  of  health.  Especially 
has  this  to  be  remembered  in  those  cases  where  the  spinal  pain, 
with  its  accompanying  stiffness,  is  the  result  of  weakness  rather 
than  of  any  injury  sustained.  The  weary  aching  of  myalgia, 
which  is  prone  to  arise  in  all  cases  of  prostrating  illness  (and  we 
have  seen  how  common  is  general  bodily  and  mental  prostration 
after  railway  accident),  is  not  to  be  remedied  by  the  vigorous 
manipulations  of  the  masseur,  unless  something  be  done  at  the 
same  time  to  improve   and  build   up   again   the   general    bodily 


100  EAILWAY    INJURIES. 

nutrition.  This  method  of  treatment  is  usually  more  satisfactory 
in  its  results  than  that  of  faradisation  of  the  muscles  on  either 
side  of  the  S23inal  column,  although  both  in  this  manner,  and  in 
the  galvano-faradisation  recommended  by  De  Watteville,  there 
are  j^owerf ul  means  for  improving  the  muscular  nutrition,  calling 
muscular  fibres  into  action,  and  so  relieving  the  stiffness.  What 
is  wanted  is  to  get  some  of  the  muscular  fibres  which  have  been 
disused  into  action,  and  if  by  any  chance  there  has  been  adhesion 
of  neighbouring  ligamentous  fibres  because  of  the  sprain,  move- 
ment is  imperatively  necessary  to  start  the  reparative  process. 
Thus  it  is  that  ironing  the  back  with  an  iron  as  hot  as  can 
be  borne  is  frequently  an  admirable  remedy  in  these  cases. 
The  warmth  is  good  in  itself,  the  friction  stimulates  and  restores 
the  local  circulation  both  of  capillaries  and  lymphatics,  and  the 
application  of  great  heat  to  the  skin  makes  the  patient  shrink 
and  move,  and  so  calls  fibres  into  action  over  which  he  has  no 
voluntary  control.  I  am  altogether  opposed  to  the  treatment 
of  these  spinal  sprains  by  the  application  of  spinal  jackets ; 
they  merely  postpone  to  another  day  the  treatment  which  will 
have  to  be  carried  out,  and  they  moreover  tend  to  increase  the 
rigidity,  and  make  the  ultimate  treatment  more  wearisome  and 
difficult.  Cumbrous  in  themselves,  they  do  little  but  harm. 
Nevertheless,  it  is  certain  that  patients  sometimes  find  relief 
when  they  begin  to  go  about  again  from  wearing  a  belt,  for  it 
gives  support  to,  and  j)rovides  warmth  for,  a  part  which  has  the 
sensation  of  weakness.  Kelief  also  may  be  given  sometimes  by 
wearing  a  plaster  over  the  loins,  belladonna  or  other ;  but  as  a 
matter  of  fact  the  best  relief  of  all  comes  in  time  from  daily 
exercise  and  leading  the  same  life  as  before.  A  neurotic,  gouty, 
or  rheumatic  history  and  inheritance  are  prone  to  make  all  these 
cases  troublesome,  and  any  special  element  of  the  kind  sliould 
never  be  ignored  in  considering  the  question  of  treatment. 


Need  of  2.  Wliilc,  liowcvcr,  the  vast  majority  of  the  cases  with  which 

g'"f      one  has  to  do  are  either  cases  of  simple  sprain  or  myalgia  from  a 


care  in 
cases 


spinal        lowered  condition  of  the  general  health,  the  comparatively  few 

joint  or  .  .  ^  .  .     .  •    1       n     1 

intraspinal  cascs  in  which  there  IS  more  serious  injury  outweigh  all  the  rest 
injury,  .^^  importance.  If  we  are  convinced,  by  the  abiding  character  of 
the  pain  or  by  the  involvement  of  a  nerve  trunk,  that  there  is 
inflammation,  perhaps  with  synovitis,  of  a  small  spinal  joint,  or 
some  local  meningeal  thickening,  then  it  is  very  obvious  that  a 
wholly  different  line  of  treatment  must  be  adopted,      Eest,  local 


ON   TREATMENT.  10  I 

rest,  must  be  rigidly  enforced,  and  such  help  in  the  absorption  of 
inflammatory  products  as  is  likely  to  be  given  by  local  counter- 
irritation  must  not  be  neglected.  Further,  if  there  be  any  sus- 
picion of  syphilis,  influence  must  be  brought  to  bear  on  that 
element  m  the  case  by  those  special  remedies  with  which  all 
are  familiar.  Above  all  things,  it  is  important  that  the  patient 
be  kept  under  careful  observation. 


3.  Passing  now  to  the  symptoms  which  frequently  accompany  Nem-as- 
spinal  sprain,  but  which  are  nevertheless  independent  of  it  specific 
and  are  often  found  alone, — those  symptoms  which  are  coUec-  I''"'^1T 
tively  indicative  of  neurasthenia — the  essential  line  of  treatment  abuse  of 
to  be  adopted  is  to  keep  up  the  bodily  nutrition.  A  word,  potassinm. 
however,  may  first  of  all  be  said  about  the  medicinal  treat- 
ment of  these  cases,  emphasising  at  once  and  decisively  that  there 
is  no  specific  remedy.  We  all  know  how  much  of  fashion  there  is 
in  medicine,  and  hi  the  days  when  bromide  of  potassium  was 
administered  for  almost  every  form  of  nervous  disease  it  was  the 
custom  to  fly  to  bromide,  under  the  impression  that  a  sedative 
was  essential  to  quiet  the  nerves.  In  the  early  stages  of  severe 
mental  shock,  with  its  sleeplessness,  general  nervousness,  and 
agitation,  it  is  certain  that  bromide  of  potassium  occasionally 
brings  considerable  relief ;  but  although  every  one  can  take  a 
casual  dose  of  bromide  without  harm,  the  continued  taking  of  it 
is  likely  to  be  most  injurious.  And  in  my  former  work,  as  well 
as  in  a  special  clinical  lecture  on  the  subject,^  I  ventured  to 
point  out  how  much,  and  how  often,  harm  had  been  done  in  the 
management  of  these  cases  by  the  administration  of  bromide  of 
potassium  in  frequent  doses  over  long  periods  of  time.  And  it 
is  absolutely  true  that  the  convalescence  of  many  patients  has 
only  begun  when  the  bromide  so  administered  has  been  withheld. 
The  symptoms  of  bromism,  be  it  remembered,  are  essentially 
those  of  general  depression  both  mental  and  bodily,  irritability  of 
temper,  a  continued  feeling  of  exhaustion  and  incapacity  for  any 
work,  intellectual  dulness  and  loss  of  memory,  a  sense  of  utter 
feebleness,  a  tendency  to  be  despondent  and  to  cry,  and  loss  or 
impairment  of  sexual  desire.  These,  it  will  be  recognised,  are 
very  much  the  symptoms  of  general  nervous  exhaustion  after 
railway  collisions  ;  and  it  is  certain  that  the  continued  adminis- 
tration of  bromide  of  potassium  is  likely  to  do  them  harm,  and 

1  Medical    Times   and  Gazette,  "The   Abuse    of  Bromide   of   Potassium,"  vol.    i. 
April  4,  lSS5- 


nes8 


102  RAILWAY    INJUllIES. 

seriously  prevent  their  removal.  As  Dr.  Anstie  pointed  out 
many  years  ago,  it  is  only  those  who  are  in  vigorous  bodily 
health  who  can  bear  its  prolonged  administration.  It  is  the 
potassium  which  is  the  injurious  element  in  the  salt,  and  if  it  be 
merely  desired  to  produce  sleep  and  quiet  let  the  Ijromide  of 
sodium  or  ammonium  be  given  in  preference. 


Sleepless-  4.  One  of  the  greatest  and  most  frequent  difficulties  in  these 
cases  is  to  procure  sleep,  and  the  whole  round  of  the  pharma- 
copoeia may  be  almost  gone  through  without  success.  Of  opium 
compounds  the  bimeconate  of  morphia  is  often  the  least  injurious, 
and  sulphonal  and  chloral,  with  or  without  bromide,  are  sometimes 
useful.  I  have  no  faith,  however,  in  any  one  remedy,  nor  is  any 
one  infallible.  The  patient  is  often  much  better  without  them, 
and  if  he  sleeps  much  or  little  during  the  day  there  need  be  less 
concern  as  to  his  not  sleeping  at  night,  provided  that  at  night 
he  is  not  left  alone  to  work  himself  into  a  state  of  nervousness, 
agitation,  and  fear.  Alcohol  is  of  little  or  no  use  in  these  cir- 
cumstances, and  it  may  be  said,  once  for  all,  that  patients  with 
the  symptoms  of  general  nerve  prostration  can  rarely  bear  it. 
In  the  majority  of  cases,  however,  it  is  not  the  want  of  sleep 
which  is  so  harmful,  but  the  want  of  food. 


'I'lie  bodily  5.  It  lias  already  been  pointed  out  how  often  disturbances  of 
digestion  accompany  the  symptoms  of  general  nervous  exhaustion  ; 
they  do  something  more  than  accompany,  they  are  in  themselves 
important  signs  of  the  condition ;  and  it  is  simply  an  inevitable 
part  of  the  condition  that  the  patient  cannot  take  ordinary  food 
in  the  ordinary  way.  In  a  word,  the  notion  that  he  can 
subsist  on  his  usual  three  meals  should  as  soon  as  possible  be 
abandoned,  for  otherwise  it  is  practically  certain  that  he  will 
obtain  an  insufficiency  of  food.  The  consequence  is  this,  that 
the  already  exhausted  nervous  system  is  prone  to  become  more 
exhausted  still  from  the  want  of  proper  nutrition.  The  rapid 
wasting  that  is  sometimes  seen  in  these  cases  is  often  quite  as 
much  due  to  the  want  of  food,  as  to  any  direct  effect  upon  the 
nervous  centres  themselves.  Easily  assimilable  food  must  there- 
fore be  given  in  small  quantities  at  frequent  intervals,  and  neither 
at  night  nor  by  day  should  the  patient  be  long  without  it.  Just 
as  convalescence  has  frequently  set  in  when  bromide  of  potassium 
has   been    withheld,    so    also    it    is    true   that   convalescence   is 


ON    TREATMENT.  IO3 

frequently  seen  to  begin  at  the  moment  when  special  attention 
is  directed  to  this  matter  of  providing  adequate  nutrition  and 
food.  And  what  follows  in  its  train  ?  An  improved  sense  of 
bodily  well-being  and  a  diminution  of  the  myalgia  from  easily 
induced  muscvilar  fatigue,  and,  above  all  things,  very  often  the 
return  of  something  like  natural  sleep,  l^ood  is  the  thing 
to  break  through  the  vicious  circle  which  encompasses  the 
patient. 


6.  There    is    yet    that    other    class    of    cases    in    which    the  Hysterical 
voluntary  taking  of  food  is   difficult,  and  where  there  is  per-  the  need 
haps   a   more  decidedly  hysterical   element   acting  prejudicially  t-'on!°xhe 
on  the  symptoms.      The   symptoms   alone   defy  treatment ;   the  Weir 
patient,  if  the  expression  may  be  used,  has  to  be  treated  as  a  treatment, 
whole.      His  surroundings  are  objectionable,  and  the  sympathy 
of    his   friends    is    misdirected    and    injurious.      Removal    from 
home  is  almost  an  essential  part  of  the  treatment,  and  there  are, 
perhaps,  few  cases  in  which  the  Weir  Mitchell  treatment  in  its 
entirety — isolation,  massage,  and  excessive  feeding — is  so  likely 
to  be  followed  by  good  results.      Isolation  frees  him  from  that 
sympathy  whicli  fosters  and  keeps  alive  the  mental  attitude  of 
the  patient  towards  his  own  case,  and  the  feeding,  together  with 
the  massage,  provide  the  nutrition  and  the  physiological  stimulus 
of  exercise  of  which  he  is  so  sorely  in  need.      It  is  very  often,  of 
course,  a  matter  of  considerable  difticulty  to  induce  patients  to 
undergo  this  treatment,  for  reasons  which  are  sufficiently  obvious. 
Here  I  can  do  no  more  than  say  of  how  much  benefit  it  is  likely 
to  be,  and  how  eminently  true  this  is  of  the  cases  where  there  is 
some  definite  neuromimetic  sign  of  nervous  derangement.      Isola- 
tion will  at  any  rate  be  an  obstacle  to  frequent  examination  of 
the  patient,  a  thing  which  is  so  prone  to  keep  alive  the  mani- 
festation of  any  special  nervous  symptom. 


7.  Be  it  further  borne  in  mind  that  in  all  these  cases  of  nervous  The  value 
exhaustion  rest  is  a  very  essential  thing  in  their  management,  and  °^^^^  ^^ 
it  is  a  matter  of  supreme  importance  that  at  no  stage  of  the 
illness  shall  the  symptoms  be  aggravated  by  the  exhaustion  of 
overwork.  If  a  man  has  his  leg  broken  he  is  of  necessity 
doomed  to  rest,  but  it  is  far  otherwise  with  the  man  who  has 
not  met  with  any  physical  injury  such  as  to  prevent  him  from 
going  to  his  work  the  day  after  the  accident.      He  feels  only 


104  RAILWAY    INJURIES. 

a  little  shaken,  but  nevertheless  it  is  eminently  advisaljle  that 
such  a  man  should  for  a  time  rest  quietly  at  home.  I  am  sure 
that  in  very  many  cases  the  seAerity  and  continuance  of  the 
symptoms  have  been  due  to  want  of  rest  at  first.  The  precau- 
tion of  complete  rest  may  wisely  be  adopted  in  all  cases  of 
railway  injury,  be  the  early  symptoms  never  so  slight ;  and  at 
a  later  stage  it  is  equally  certain  that  no  perfect  rest  can  be 
enjoyed,  when  a  man  is  worrying  about  compensation  ;  just  as  the 
enjoyment  and  rest  of  a  holiday  are  assuredly  destroyed,  when 
a  man  has  his  letters  sent  after  him  to  plague  and  annoy  him. 


CHAPTER    VIL 

MALINGERING. 

Summary.— I.  Simulation  and  exaggeration:  The  attitude  of  limbs  in  joint  disease, 
— 2.  Tympanitis. — 3.  Haemorrhage. — 4.  Use  of  atropine. — 5.  Precedent  diseases. 
— 6.  Feignings  of  paralysis  and  other  symptoms  of  nerve  lesion.  —  7.  Hys- 
terical disorders  not  necessarily  feigned. — 8.  Malingering  after  railway  acci- 
dents, and  the  motive  for  it. — 9.  Anxiety  as  to  a  rightful  claim.  — 10.  Similarity 
of  methods  of  deception. — 11.  Exaggeration  of  trifling  injuries,  and  examples 
of  spurious  nervous  shock. — 12.  Relative  value  of  objective  signs  and  subjective 
symptoms. — 13.  Importance  of  a  correct  early  history.  — 14.  The  neuromimeses. 
— 15.  The  co-existence  of  sensory  derangements. — 16.  The  general  conduct  and 
bearing  of  malingerers. 

1.  "  Is  the  condition  before  us  real  or  feigned  ?  "  is  a  qviestion  Simulation 
which  we  have  sometimes  to  ask  ourselves   in   the   routine  of  geration^: 
practice.      A  correct  answer  to  it  is  ob^dously  of  great  moment  ^u^Jg^^f '' 
to  both    doctor   and   patient ;  and   I  propose,  therefore,  to  say  limbs  in 
something  on  the  special  kind  of  malingering  which  may  be  met  di.sease. 
with  after  the  injuries,  or  after  no  injuries,  received  in  railway 
accidents.      It  may  be  well,  however,  in  the  first  place,  to  name 
some  of   the  points  which  have  to   be   borne   in   mind   in  the 
endeavour  to  come  to  a  right  conclusion,  that  we  may  decide 
whether  the  signs  of  disease  before  us  be  real  or  assumed,  or  the 
complaints  we  hear  be  genuine  or  the  outcome  of  wilful  exaggera- 
tion ;  whether,  indeed,  to  adopt  the  classification  of  Ogston,  the 
disease  be  feigned,  factitious,  exaggerated,  or  aggravated.      It  is 
a  common  experience  that  most  feigned  disorders  have  in  them 
some  basis  of  reality,  or  some  revival  of  the  symptoms  of  a  former 
lesion  or  injury  used  again  for  purposes  of  deception.     Eamiliarity 
with  the  phenomena  and  history  of  disease  can  alone,  therefore, 
enable  a  man  to  pronounce  with  certainty  as  to  the  real  nature 
of  any  particular  disorder,  and  to  detect  the  mistakes  into  which 
malingerers  so  often  fall. 

An  apt  illustration  may  be  taken  from  the  attitude  and  posi- 
tion of  joints  in  real  and  assumed  disease.  By  his  loud  com- 
plaints a  man  may  wish  to  suggest  the  presence  of  destructive 
mischief  in  a  joint,  Ijut  in  all  probability  he  will  go  wrong  in 

105 


I06  RAILWAY    INJURIES. 

the  attitude  and  pusition  which  he  gives  to  his  Hmb.  Or  without 
pretending  to  be  afflicted  with  actual  joint  disease,  a  patient  will 
sometimes  affirm  that  a  joint  has  become  stiff,  and  that  it  is 
impossible  to  move  his  arm  or  leg.  It  is  unnecessary  to  make 
any  mention  here  of  the  recognised  causes  of  stiffness  and 
anchylosis  of  joints ;  suffice  it  that  the  entire  absence  of  them, 
both  in  the  history  of  the  case  and  in  the  course  of  the  disease, 
will  reveal  a  tlaw  in  the  evidence  sufficient  to  raise  suspicion. 
Suspicion  grows  into  tolerable  certainty  if  you  are  careful  to 
observe  the  conduct  of  the  person  under  examination. 

A  man  complained  that  he  could  not  work  because  of  stiffness 
in  the  right  elbow  and  inability  to  straighten  his  arm.  He  said 
he  had  fallen  on  his  elbow  a  month  before,  but  it  was  clear  fi'om 
his  answers  to  questions  that  the  injury  had  not  been  at  all  severe. 
Comparison  of  the  two  elbow-joints  showed  an  entire  absence  of 
physical  signs,  and  there  was  no  wasting  of  the  limb.  Noticing, 
in  examination,  that  attempts  to  ilex  or  extend  his  arm  were 
forcibly  resisted,  he  was  told  to  look  in  the  opposite  direction, 
questions  were  asked  him  unconnected  with  his  arm,  and  there 
was  no  difficulty  in  bringing  it  at  once  to  natural  and  full  exten- 
sion. A  turn  of  his  head  and  eyes  towards  the  affected  limb  was 
immediately  followed  by  active  flexion  to  the  original  degree. 
Complete  flexion  also  could  be  produced  under  like  circumstances. 
Examination  of  both  arms  simultaneously  seemed  to  confuse  him, 
for  he  called  out  with  pain  when  pressure  was  made  on  the  sound 
limb.  Such  inconsistencies  as  were  met  with  here  ought,  at  any 
rate,  to  place  us  on  our  guard.  A  man  based  a  large  demand  for 
compensation  from  a  railway  company  on  stiffness  of  his  elbow  and 
inability  to  move  his  arm,  the  result  of  a  collision.  A  verdict  in- 
commensurate with  his  expectations  having  been  recorded,  he  threw 
up  his  arms  and  exclaimed,  "  My  God  !   I'm  a  ruined  man." 


Tytn-  2.  Furthermore,   an    impostor  may  adopt   devices   to  produce 

conditions,  which,  in  themselves  alarming,  are  yet  seen  to  be 
without  significance  when  every  feature  of  the  case  is  examined. 
A  prisoner  took  to  his  bed  complaining  of  great  pain  and  swelling 
of  the  abdomen.  Although  the  belly  was  enormously  distended 
and  tympanitic,  there  was  no  other  sign  of  illness  about  him, 
and  there  was  an  entire  absence  of  any  one  condition  on  which 
tympanitis  usually  depends.  After  a  few  days'  observation,  and 
having  carefully  weighed  all  the  facts  of  the  case,  the  surgeon 
came    to   the    conclusion    that    the    man    purposely   induced   the 


MALINGERING.  10/ 

distension  by  swallowing  air.  Loudly  enough  for  the  prisoner  to 
hear  him,  he  accordingly  remarked  to  the  warder,  "  When  I  come 
to-morrow  I  shall  bring  an  instrument  to  tap  him."  On  the 
morrow  the  tympanitis  had  disappeared.^ 


3.  More  common  are  the  cases  where  patients  assure  yon  that  H?emor- 
they  are  losing  blood  in  large  quantities  from  the  bowel.  The  '°  ' 
causes  of  hgemorrhage  from  the  bowel  are  well  known,  although 
an  exact  diagnosis  may  be  sometimes  difficult  because  of  their 
very  number  and  variety.  The  malingerer,  however,  does  not  know 
that  profuse  haemorrhage — and  it  is  of  profuse  haemorrhage  of 
which  he  invariably  complains — gives  rise  to  well-defined  symptoms 
due  to  loss  of  blood.  Who  ever  saw  a  patient  losing  blood,  either 
in  alarming  quantities  or  in  small  amounts  spread  over  a  long  time, 
with  a  florid  lip,  a  tranquil  pulse,  a  cool  skin  ?  Should  not  the 
presence  of  every  indication  of  health  warn  us  that  we  have  to 
deal  with  something  altogether  unusual  ?  Should  we  be  doing 
rightly  if  we  paid  little  or  no  attention  to  the  general  condition 
of  the  patient,  and  endeavoured  to  estimate  his  case  by  simply 
hearing  the  story  he  told  us,  without  examining  the  blood  which 
he  showed  ?  By  neglect  of  such  simple  precautions  an  erroneous 
diagnosis  was  made  of  a  case  where  pints  of  blood,  not  the  man's 
own,  were  presented  as  having  been  passed  jper  Tectum  ;  and  the 
same  thing  happened  in  another  case  where  a  man  showed,  from 
the  same  supposed  source,  prodigious  quantities  of  "  blood  and 
corruption."  Both  were  cases  of  imposition — subsequently  known 
and  proved — after  railway  accidents  ;  and  yet  in  both  of  them 
the  fraud  was  successful.  Surel}"  when  conditions  such  as  these 
occur  alone,  when  there  is  neither  discoverable  cause,  nor  the  usual, 
inevitable  result,  one  ought  to  be  able  to  say  of  them  at  once, 
"  Impossible,  untrue  !  " 


4.   In  the  same  category  it  is  not  amiss  to  refer  to  dilatation  of  Use  of 
pupil  induced  by  the  use  of  atropine,  a  point  of  some  importance,  ^  '°i'"'®- 
because  it  has  been  shown  in  a  previous  chapter  that  a  wide 
sluggish  pupil  is  a  valuable  sign  of  loss  of  nerve  tone.      "  The 

1  The  same  method  of  imposture  is  recorded  by  Gavin  (Feigned  and  Factitious 
Diseases,  p.  299),  who  writes:  "This  affection,  tympanitis,  has  been  so  successfully 
feigned  as  to  deceive  a  board  of  French  medical  officers  ;  but  this  individual  pos- 
sessed the  extraordinary  power  of  greatly  distending  his  abdomen  by  swallowing  air. 
He,  however,  obtained  an  unqualified  exemption  from  military  service  by  presenting 
himself  in  this  state,  with  clothes  made  for  the  occasion." 


I08  RAILWAY    INJURIES. 

access  to  atropine  or  belladonna,"  writes  Mr.  Hutchinson,  "  on 
the  part  of  the  public  is  now  so  easy  that  we  cannot  be  surprised 
that  we  encounter  mydriasis  as  the  result  of  an  accidental  and 
perhaps  unknown  use  of  this  agent,  or  of  its  use  with  intention 
to  deceive.  It  is  the  first  question  which  will  occur  to  a  surgeon 
on  seeing  a  dilated  pupil,  '  Has  atropine  been  used  ? '  and  he 
must  be  on  his  guard  in  cases  of  hasty  denial.  .  .  .  Xot  un- 
frequently  the  ophthalmic  surgeon  has  to  encounter  cases  of 
intentional  deception.  These  occur  usually  in  young  women  of 
emotional  tendencies.  ...  A  highly  cultivated  young  lady  con- 
sulted me  for  'pemphigus.'  She  had  blebs  all  over  the  left  half 
of  her  body.  But  these  blebs  were,  some  of  them,  not  round 
but  oblong,  in  a  style  which  no  skin  disease  ever  assumes,  and 
very  obviously  the  result  of  the  application  of  a  brush.  She 
was  liable  also,  I  was  told,  to  attacks  of  dilatation  of  the  pupils 
and  loss  of  ability  to  read.  These  attacks  usually  lasted  a  week. 
This  case  is  only  an  example  of  what  has  frequently  come  under 
my  notice.  Although  it  is  possible  to  use  atropine  in  such  a 
weak  sokition  that  the  ciliary  muscle  is  not  affected,  yet  in  most 
of  these  cases  a  more  complete  effect  is  obtained,  and  the  loss  of 
power  to  read  is  produced  in  addition  to  mydriasis.  If  the  latter 
be  present  alone,  and  if  it  persist  for  long,  the  suspicion  of  decep- 
tion may  be  put  aside."  ^  In  all  cases  where  the  use  of  atropine 
is  suspected,  it  is  essential  to  examine  the  patient  frequently,  and 
carefully  look  for  some  concomitant  and  confirmatory  symptom  of 
nerve  disturbance.  The  pupils,  moreover,  it  need  hardly  be  said, 
must  be  examined  both  in  light  and  shade ;  and  it  should  be  borne 
in  mind  that,  where  there  is  inequality  of  the  two  pupils,  the 
dilated  pu2:)il  need  not  necessarily  be  the  one  affected.  The  pupil 
which  is  the  smaller  of  the  two  may,  for  example,  be  unable  to 
dilate,  and  be  the  one  really  at  fault,  because  of  sympathetic 
paralysis — a  condition  of  things  by  no  means  unknown  after 
organic  injury  to  the  lower  cervical  spine.  The  question  might 
here  arise  whether  eserine  had  been  used,  but  I  am  not  aware 
that  eserine  can  induce  the  other  signs  of  sympathetic  paralysis 
— shrinkage  of  the  globe,  and  contraction  of  the  palbebral  fissure. 


Precedent  5.  Let  it  not,  moreover,  be  forgotten  that  any  kind  of  old 
injury,  deformity,  or  want  of  perfect  symmetry  may  provide  the 
malingerer  with  the  opportunity  for  the  practice  of  imposture. 

'  "  On  the  Symptom-significance  of  Different  States  of  the  Pupil,"  Brain,  vol.  i. 
p.  462. 


MALINGERING.  I09 

Hydroceles,  varicoceles,  and  liernige  ;  fatty  tumours,  sloughing 
gummata,  and  sebaceous  cysts ;  distended  bursse,  and  anchylosed 
joints  from  long  past  disease,  are  some  of  the  conditions,  which, 
in  my  own  experience,  have  been  attem  pted  to  be  palmed  off  as 
the  result  of  railway  shock.  No  man  ^yho  knows  his  business  can 
be  taken  in  by  such  things  as  these.  Great  care,  however,  must 
be  always  exercised  in  the  examination  and  estimation  of  abnormal 
conditions  which  may  be  presented,  that  no  injustice  may  be  done 
a  man  in  coming  to  a  hasty  conclusion  that  he  is  malingering. 

It  is  singular,  for  example,  how  ignorant  some  persons  seem  to 
be  of  the  existence  of  deformities,  or  states  of  body,  which  must 
have  been  endured  for  a  long  time. 

Case  26. —  Case  of  old  lateral  curvature  of  the  spine — CoTulition 
unhioivii  to  tlwpatieiit. — A  man,  seventy  years  of  age,  came  to  St. 
Mary's  Hospital,  complaining  of  pain  over  the  right  side  of  the 
thorax.  When  he  had  been  stripj)ed,  it  was  found  that  he  had 
lateral  curvature  of  the  spine  to  an  extreme  degree.  He  said 
that  this  condition  was  of  quite  recent  date,  and  that  he  had 
only  noticed  it  since  he  felt  the  pain.  Judged  by  itself  alone  his 
story  was  enough  to  cause  alarm  ;  but,  both  from  the  ossification 
of  his  costal  cartilages,  and  from  the  fact  that  there  had  been 
no  alteration  in  his  stature,  it  was  clear  that  the  spinal  curvature 
was  of  old  standing,  in  all  probability  nearly  as  old  as  the  man 
himself.  Had  it  been  an  acute  change  at  this  time  of  life,  and 
had  the  pain  which  brought  him  to  the  hospital  been  due  to  the 
curvature,  or  been  a  symptom  of  some  serious  malady  which  lay 
behind  it,  a  simple  liniment  and  a  tonic  would  hardly  have 
restored  him  in  a  short  time  to  his  usual  state  of  health. 

So  also  the  absence  of  perfect  symmetry  between  the  two 
halves  of  the  body,  some  trifling  difference  in  the  facial  lines,  or 
slight  excess  in  size  of  one  limb  over  the  other,  and  of  one  half 
of  the  spinal  muscles  over  the  other  half,  may  be  regarded,  when 
taken  by  themselves,  as  evidence  of  very  grave  disease. 

Case  27. — Farnlysis  from  pressure  on  muscido-spiral  nerve — 
Accomioanying  facial  asymmetry. — A  labourer,  aged  forty-two,  came 
to  the  hospital  on  June  i  2 ,  saying  that  on  waking  from  his  usual 
nap  after  dinner  the  previous  afternoon,  he  found  his  right  arm 
and  hand  "numb,"  his  fingers  and  thumb  flexed,  and  his  wrist 
dropped.  This  paralysis  of  the  extensor  muscles  was  partial 
only,  and  was  accompanied  by  some  tenderness  above  the  elbow 
on  the  inner  side  of  the   arm,   and  by   a  small  anassthetic  area 


no  IIAILWAY    INJURIES. 

over  the  ball  of  the  thumb.  As  usual,  recovery  was  slow,  and, 
although  he  was  then  able  to  work,  he  had  not  regained  full 
use  of  his  wrist  and  hand  when  he  was  seen  six  weeks  after- 
wards. Interesting  though  this  part  of  the  case  may  be,  the 
special  point  about  it  was  the  fact  that  the  left  side  of  the 
man's  face  was  almost  entirely  wanting  in  facial  lines,  while 
their  presence  on  the  right  side  gave  him  the  appearance  of 
having  left  facial  paralysis.  To  the  palsy  of  the  arm  there  thus 
appeared  to  be  added  paralysis  of  one  side  of  the  face,  and  the 
combination  might  have  suggested  grave  disease,  had  not  a  care- 
ful inquiry  into  every  circumstance  of  the  case  led  to  the  diagnosis 
that  this  asymmetry  was  peculiar  to  the  individual.  And  this 
opinion  was  subsequently  confirmed  by  the  patient  himself.  Yet 
how  easily,  under  the  besetting  temptations  of  railway  injury, 
might  a  hastily  expressed  conclusion  as  to  the  pathological  origin 
of  such  a  state  have  given  an  unscrupulous  patient  the  oppor- 
tunities of  using  his  natural  peculiarity  for  purposes  of  decep- 
tion and  fraud.  We  meet  with  such  conditions  every  day,  and 
it  is  of  supreme  importance  to  recognise  and  rightly  estimate 
them,  not  only  that  we  may  allay  the  anxiety  of  the  patient  who 
honestly  believes  his  old  complaint  is  new,  but  also  that  we  may 
nip  the  means  of  deception  in  their  veiy  bud,  and  not  ourselves 
unwittingly  befriend  the  imposture. 


Feignincrs  6.  I  shall  not  attempt  to  enter  in  any  detail  into  the  feign- 
and^otUr''  ings  of  paralysis  and  kindred  nerve  diseases.  The  same  principles 
symptoms  j^^^g^  rruide  US,  and  WB  shall  find  them  very  seldom  fail.      The 

or  nerve  a  >  _  ^  •/ 

lesion.  artifice  may  be  clever  and  well  devised  ;  it  may  be  long  sustained 
and  free  from  variation  ;  but  it  is  very  difficult,  and  therefore  rare, 
for  the  malingerer  to  simulate  a  real  disease  with  accuracy.  He 
exaggerates ;  that  which  he  could  not  do  he  does ;  he  will  not 
do  that  which  he  could  do  if  his  state  were  real ;  and  you  find 
that  his  symptoms  are  such  as  you  have  never  seen  or  known 
resulting  from  any  affection  of  the  brain,  the  spinal  cord,  or  the 
nervous  system  generally.  Subjective  symptoms  largely  pre- 
dominate, and  you  observe  that  such  objective  symptoms  as  he 
has  are  mostly  those  over  which  he  can  exercise  his  will.  He 
cannot  make  his  eyelid  droop ;  his  tongue  does  not  always 
deviate,  nor  is  the  angle  of  his  mouth  always  drawn ;  he  knows 
not  how  to  paralyse  his  bladder  ;  there  are  no  bed-sores ;  he  does 
not  waste  ;  his  palsied  limb  resists  examination  ;  his  fits  occur  at 
convenient  moments  when  he  cannot  harm  himself,  or  when  he  can 


MALINGEEING.  I  I  I 

be  under  the  observation  of  those  who  do  not  know  their  import 
or  their  signs  ;  in  his  coma  he  is  not  unconscious  ;  and  added  to  all 
he  has  the  aspect  of  health,  nor  is  any  vital  function  deranged.^ 


7.  The  so-called  functional,  hysterical,  and  neuromimetic  dis-  Hysterical 
orders  have  many  symptoms  which  often  look  like  imposture,  but  not°neces- 
I  believe  that  the  sufferers  who  present  them  are  prone  to  deceive  warily 
themselves  more  than  other  people.  That  the  manifestations  of 
hysteria  are  not  necessarily  feigned,  or  due  to  expectant  attention, 
is  indeed  shown  by  the  fact  that  they  may  be  found  even  in 
young  children,  who  have  what  may  be  called  the  requisite 
hysterical  neurosis.  Some  remarkable  cases  of  '•  hysterical  anal- 
gesia in  children "  recorded  by  Dr.  Barlow,"  show  conclusively 
that  a  symptom  of  hysteria,  which  in  the  adult  may  lead  to 
the  suspicion  of  imposture,  may  be  seen  in  children  so  young 
that  the  very  idea  of  feigning  is  out  of  the  question.  As  I 
have  already  pointed  out,  the  one  common  characteristic  of  all 
these  cases  lies  in  a  strange  perversion  and  abeyance  of  voli- 
tional power  or  will,  whereby  each  action,  word,  and  thought 
seem  to  run  riot,  as  it  were,  for  want  of  due  control.  Largely 
unreal  and  independent  of  structural  change,  the  symptoms 
admit  of  easy  exaggeration  and  representation  whenever  the 
uncontrolled  whim  of  the  moment  allows ;  but  having  grown, 
step  by  step,  out  of  slighter  conditions  which  there  was  neither 
the  wish  nor  the  determination  to  subdue,  they  seem  in  their  very 
nature  to  exclude  deliberate  imposture.  Practically,  too,  the  kind 
of  treatment  these  disorders  require  is  very  difterent  from  that 
which  suflBces  to  cure  ailments  altogether  feigned.  Be  the  condition, 
however,  what  it  may,  to  the  patients  themselves  it  is  very  real : 
the  pain,  the  stiffness,  the  palsy,  are  as  great  to  them  as  they  are 
described,  or  as  full  of  evil  consequences  as  it  is  imagined  and 
believed.  The  symptoms  may  be  of  little  moment  in  them- 
selves, but  it  is  wrong  to  look  upon  them  as  altogether  feigned. 

The  cases  already  given  in  illustration  of  some  of  the  points 
and  principles,  which  it  behoves  us  to  bear  in  mind,  have  been 

1  "  In  peripheral  paralysis  of  the  facial  the  expression  of  the  face  is  very  striking, 
for,  owing  to  the  loss  of  muscular  tension  on  one  side,  it  falls,  whilst  the  opposite 
side  is  drawn  up.  This  di.^tortion  is  much  increased  in  smilinjj  or  talking,  or  when- 
ever the  influence  of  the  will  is  exerted  on  the  musclt- s  "  (Wilks,  op.  cit.,  p.  439). 
But  in  laughing  or  talking  the  impostor  moves,  he  cannot  help  moving,  the  paralysed 
side,  and  the  asymmetry  becomes  less  instead  of  more  obvious.  I  have  a  case  iu 
mind. 

-  British  Medical  Journal,  vol.  ii.  p.  892.      1S81. 


I  I  2  RAILWAY    INJURIES. 


designedly  drawn  from  ordinary  hospital  work ;  and  they  are  of 
value  in  showing  that  no  sjDecial  practice  is  required  to  teach 
important  lessons  bearing  upon  the  subject,  and  that  these  can 
be  learned  from  cases  which  are  met  with  every  day. 


Maiin<,'er-        8.  As  I  havc  already  said  in  speaking  of  the  after-history  of 
nithvay      ucrvous   shock,  SO   now   in   turning  to   the   more   special   topic 
nnd'the*^'    ^^    maKugering    after    railway   accidents,  it    must    be    acknow- 
niotive       ledgcd    that    ordinary    hospital    patients    provide    little    ojjpor- 
tunity   for   gaining   familiarity   with    the    kind   of    malingering 
with  which  we  have  now  to   deal.      This,  however,  has    to   be 
noted,   tliat,   whatever   may    be   said    of    every    other   form    of 
malingering,    there    is   no    obscurity   or   doubt   in    the    case   of 
railway  injuries  as  to  the  motive  which  may  induce  a  man  to 
exaggerate    or    to    assume    symptoms   of    disease.      It    may    be 
summed   up   in    the    one   word   "  compensation,"    to   which   the 
law    of    the    land    entitles    him,    whether    for    damage    to    his 
person  or  loss  in  Ms  business  consequent  on  the  negligence  of 
the  public   company   which   had   engaged  to   carry   him.     Has 
his  injury  been  great ;  has   he   lost  a  limb,  or  been  otherwise 
maimed ;  or  has  his  life  been  then,  or  in  the  future,  imperilled ; 
it    is    almost    needless    to    remark    that,    while   no   money   can 
adequately  compensate  him,  the  amount  to  be  paid  hun  must 
of  necessity  be  large.      "V\lien,  however,  the  injury  is  trivial  and 
passing,  when  tliere  is  neither  structural  damage  nor  prospect 
of   lasting    enfeeblement  of    body  or   mind,  it  is   evident    that 
the  amount  of  money  sufficient  to  compensate  him  ouglit  to  be 
very  small.     And  herein,  in  the  endeavour  to  gain  large  com- 
pensation  for   small   injuries,  the   malingerer   finds   reason  and 
excuse  for  practising  deception  in  order  to  magnify  his  claim. 
The  motive  is  one  requiring  great  moral  courage  to  resist.    Many 
a  man,  whose  character  hitherto  has  known  no  stain,  has  yielded 
to  the  temptation,  and  has  thereby  lowered  himself  in  general 
esteem.      It  is  not  the  language  of  sentiment  but  of  sober  fact, 
when   it   is   said    that   whole   households   are   sometimes    made 
miserable  by  the  devices  to  which  it  is  needful  to  resort,  in  order 
to  obtain  the  desired  end.      Hopes  are  conceived  of  future  gain, 
thoughts  are  centred  on  the  one  aim  in  view,  and  there  is  but  a 
sorry  consolation  when  the  day  of  reckoning  has  come.     So  power- 
ful indeed  is  the  motive  that  you  find  persons  taking  to  their  beds, 
abstaining  from  food,  shutting  themselves  up,  neglecting  their  busi- 
ness, and  making  themselves  weak  in  body  and  wTetched  in  mind. 


MALINGERING.  I  I  3 

9.  While,  however,  this  has  to  be  written  of  those  who  wil-  Anxiety  as 
fully  malinger,  it  would  be  doing  many  an  injustice  if  we  did  fuuiafm! 
not  recognise  that  prospective  compensation  may  exert  a  retard- 
ing influence  on  the  process  of  recovery  quite  apart  from  any 
deliberate  imposture.  Entitled  as  he  is  to  compensation,  it  is 
only  natural  and  right  for  a  man  to  feel  anxiety,  both  in 
his  own  interests  and  in  the  interests  of  his  family,  that  com- 
pensation should  be  adequate  and  fair,  and  a  nervous,  yet  really 
honest,  dread  may  be  engendered  lest  some  mistake  be  made  in 
the  settlement  of  a  rightful  claim.  The  injurious  influence  of 
any  such  nervousness  and  suspense  is  sufficiently  obvious,  and  it 
may  sometimes  be  a  matter  of  no  small  difiiculty  to  determine 
whether  the  protraction  and  aggravation  of  a  man's  illness  are 
really  due  to  one  cause  or  the  other — to  wilful  imposture  taking 
the  form  of  not  choosing  to  recover,  or  to  the  unconscious  weight 
round  his  neck  which  arises  from  apprehension  as  to  compensa- 
tion. I  have  never  known  any  difiiculty,  however,  in  making 
the  honest  sufferer  understand  how  and  why  the  settlement  of 
his  claim  for  compensation  will,  more  readily  than  drugs  or  change 
of  air,  promote  his  recovery  and  work  only  for  his  good.  Some 
may  think  that  there  need  not  be  much  regard  for  the  feelings 
of  an  impostor. 


10.   Curiously   alike  are  the  means   of  deception  adopted  in  Similarity 

i-nn  ,  1      -i       •  1  T  1  •        j_i       of  methods 

dinerent  cases,  and  it  is  extraordinary  how  persons  m  the  of  decep- 
humbler  walks  of  life  possess  a  knowdedge  of  the  kinds  of  injury,  *'""■ 
which  are  popularly  deemed  inevitable  in  a  collision.  Provincial 
journals  are  to  some  extent  responsible  for  this,  for  in  them  are 
often  to  be  found  in  considerable  detail  the  history  and  symptoms 
of  those  who,  by  litigation  or  otherwise,  have  received  compen- 
sation from  railway  or  tramway  companies.  And  if  a  man  has 
in  this  way  learned  that  large  compensation  w^as  awarded  for 
injuries  apparently  like  his  own,  it  is  a  great  temptation  to 
him  to  adopt  courses  which  seem  to  him  potential  of  future  gain. 
A  publican  well  up  in  years  made  an  exorbitant  claim  for  trifling 
injuries.  His  enlarged  prostate  gave  rise  to  the  usual  symptoms, 
but  when  it  was  pointed  out  to  him  that  this  was  the  real  cause 
of  his  urinary  trouble,  he  replied,  "  No,  it  is  my  spinal  cord  to 
which  all  my  symptoms  are  due."  "  Drag  your  leg,  you  fool ; 
don't  you  see  the  doctor  coming  ? "  called  out  by  a  workman  to 
his  fellow,  who  had  been  in  an  accident,  and  heard  by  the  doctor 
as  he  was  then  crossing  the  yard  to  see  him,  was  but  the  audible 

H 


114  RAILWAY   INJURIES. 

expression  of  many  a  like  lesson,  which  may  be  learned  with 
ease  in  the  solitude  of  a  sick  room.  And  as  the  views  of  the 
nature  of  railway  injuries  have  changed,  so  also  has  there  been  a 
notable  change  in  the  methods  of  imposture.  Ten  years  ago  the 
malingerer  could  not  walk,  or  he  dragged  his  leg  because  of  some 
obscure  injury  to  the  spine ;  nowadays  he  presents  an  admirable 
picture  of  nerve  prostration,  for  his  nervous  system  has  had  a 
severe  shock,  the  consequences  of  which  are  readily  induced  by 
abstinence  from  food.  This  is  unquestionably  a  far  better  way 
of  malingering  than  the  endeavour  to  simrdate  some  spinal  disease, 
for  the  fraud  in  that  case  can  be  soon  found  out ;  but  in  the 
ease  of  wilful  starvation  it  is  only  a  question  of  time  when  your 
waistcoat  will  hang  flabbily  about  you,  and  you  can  measure  at 
any  automatic,  and  thoroughly  trustworthy,  machine  the  number 
of  stones  you  have  lost  in  weight.  It  caused  no  surprise  at  all 
that  a  man,  who  had  been  going  about  on  crutches  for  months, 
should  have  led  off  the  dance  at  a  ball  which  he  gave  to  his 
rejoicing  friends  at  the  close  of  litigation ;  but  I  have  heard 
expressions  of  genuine  amazement  at  the  speed  with  which  the 
human  form  di\Tine  has  sometimes  put  on  flesh. 


Exagpera-  11.  And  yet  it  is  imusual,  in  my  experience,  to  meet  with  cases 
trifling  in-  where  it  would  be  possible  to  say  with  certainty  that  no  injury 
Junes  and  -^^^  heen  received  at  all.     The  pain  of  some  trifling  bruise  or 

examples  -r  c 

of  spurious  strain  is  exaggerated  and  unduly  prolonged,  and  thence  are  de- 
shock,  veloped  other  conditions  and  complaints,  in  whose  very  obscurity 
lie  the  ready  means  of  untruthfulness  and  deception.  The  still 
widespread,  yet  erroneous,  impression,  that  the  effects  of  a  rail- 
way collision  are  likely  to  be  remote,  does  much  to  foster  a  sense 
of  uncertainty  and  alarm,  and  to  give  the  malingerer  scope  for 
the  course  which  he  intends  to  pursue.  And  so  it  comes  to  pass 
that  it  is  after  the  most  trivial  accidents,  or  in  cases  where  no 
definite  injury  has  been  sustained  upon  which  to  base  a  claim, 
that  we  hear  most  often  of  the  obscure,  subjective,  and  intangible 
symptoms  and  complaints,  which  are  supposed  to  indicate  some 
serious  damage  to  the  nervous  system,  and  to  forbid  all  prospect 
of  future  recovery.  Is  it  not  a  strange  anomaly,  something 
altogether  extraordinary,  that  it  is  only  the  slightest  injuries 
which  are  followed  by  these  purely  subjective  symptoms,  whose 
very  obscurity  gives  rise  to  alarm  ?  Is  not  some  light,  however, 
thrown  upon  them  by  the  facts  of  accumulated  experience,  that 
these  symptoms  vanish  and  the  complaints  are  no  more  heard 


MALINGERING.  I  I  5 

when  the  motive  for  their  existence  is  at  an  end  ?  Have  we 
not  strong  grounds  for  doubting  their  genuineness  and  reality  ? 
Are  we  right  in  ignoring  the  absence  of  early  symptoms  and 
signs  of  injury  or  shock,  and  in  assuming  that  a  condition  is 
alarming,  or  a  prognosis  grave,  simply  from  assurances  of  the 
patients  themselves  ?  And  yet  this  is  what  is  seen  far  too  often 
in  dealing  with  cases  of  alleged  injury  after  railway  accidents. 
Little  regard  is  paid  to  the  early  condition  and  to  the  actual 
state  of  the  patient,  and  undue  attention  is  given  to  ceaseless 
complaints  of  hidden  symptoms,  whose  real  existence  you  should 
be  all  the  more  cautious  in  acknowledging,  being  as  they  are 
without  objective  signs,  and  traceable  to  no  injury  met  with  in 
the  beginning.  Time  runs  on,  the  complaints  become  louder  and 
more  continuous ;  and  forensic  eloquence,  it  may  be,  is  left  to 
tell  a  harrowing  tale  of  the  frightful  collision,  and  of  a  nervous 
system  shattered  and  beyond  repair. 

I  trust  that  I  am  not  myself  lapsing  into  the  "  region  of  7iisi 
prius."  These  are  facts,  however,  and  it  would  be  well  if  they  were 
more  widel}''  known.  That  cases  of  severe  and  unquestionable  in- 
jury should  usually  go  on  to  recovery,  or  to  such  restoration  as  the 
nature  of  the  injury  will  allow ;  and,  on  the  other  hand,  that  cases  of 
slight  injury,  from  which  recovery  without  complication  or  sequelae 
is,  in  other  circumstances,  the  rule,  should  after  railway  collision  be 
followed  by  innumerable  and  protracted  subjective  symptoms  on 
which  not  a  finger  can  be  laid,  are  facts  to  arrest  attention  and 
to  call  for  explanation.  And  the  simplest  explanation  is  the 
best.  In  the  one  set  of  cases  there  is  an  obvious  basis  of  com- 
pensation for  the  definite  injuries  received ;  while  in  the  other 
there  is  little  or  none,  and  there  arise  exaggeration  and  unreality, 
and  subjective  symptoms  to  make  the  specious  foundation  of  a 
claim.  But  enough,  perhaps,  directly  and  indirectly,  as  to  the 
motive  for  malingering.  It  is  notorious,  and  it  has  an  all-power- 
ful influence  over  the  course  and  symptoms  of  railway  injuries. 

Let  us  now  learn  from  definite  examples  something  of  the 
ways  of  malingerers. 

Case  28. — Slight  sprain  and  nervous  sJiocJc — Protracted  symp' 
toms  from  ivilful  starvation. — A  travelling  agent,  aged  fifty-eight, 
received,  in  a  trifling  collision,  a  blow  over  the  right  iliac  crest. 
He  complained  to  a  fellow-passenger  at  the  time,  so  he  said,  of 
being  hurt,  and  of  feeling  rather  faint.  There  was  never  any 
mark  of  bruising,  and  his  medical  attendant — a  hospital  surgeon 
well  able  to  judge — thought  his  injury  altogether  trivial.      The 


I  I  6  RAILWAY   INJURIES. 

patient,  however,  abstained  from  Lis  work ;  nor  did  he  resume  it 
until  eleven  months  had  passed  away.  During  this  time  he 
complained  of  pain  about  the  right  hip,  which  compelled  him  to 
use  a  stick  and  made  him  walk  lame  ;  of  pain  in  the  head  ;  of 
inability  to  sleep  ;  of  poor  appetite  and  nausea  ;  of  constipation ; 
of  such  general  weakness  as  to  prevent  him  from  walking  a  mile, 
and  that  only  now  and  then ;  of  impaired  vision,  so  that  he  could 
only  read  the  largest  type  ;  of  loss  of  memory ;  and  of  incapacity 
to  apply  his  mind  to  anything,  so  that  neither  physically  nor 
mentally  did  he  feel  himself  fit  for  any  occupation.  He  frequently 
stayed  in  bed  for  the  whole  day,  and  rarely  got  up  before  twelve ; 
for  days  together  he  never  went  out  of  doors,  and  he  took  the 
very  smallest  quantity  of  food.  Thus  he  gradually  acquired  a  worn 
and  anxious  aspect,  and  looked  pale,  thin,  and  ill.  No  known 
means  of  examination  were  able  to  discover  any  sign  whatever 
of  injury  or  disease  ;  and  although  he  twice  undertook  journeys 
of  some  two  hundred  miles  to  be  seen  by  a  well-known  oculist, 
could  I  ever,  with  the  ophthalmoscope,  find  a  trace  of  disease 
in  his  eyes,  or  any  cause  for  his  loss  of  vision.  No  remedies 
adopted  seemed  to  have  the  slightest  effect  upon  him.  Liniments 
did  not  soothe  his  pain,  soporifics  did  not  make  him  sleep,  and 
tonics  improved  neither  his  appetite  nor  his  strength.  On  only 
one  occasion  did  he  give  a  clue  to  the  absence  of  perfect  genuine- 
ness and  reality  in  this  case.  To  the  surgeon  who  had  several 
times  examined  him  by  request  of  the  railway  company,  the 
patient  one  day  remarked  as  he  left  the  house,  "  You've  got  a 
cobweb  on  your  hat,  perhaps  you'd  like  to  brush  it  off"  He  was 
known  to  be  at  this  time,  and  he  had  been  formerly,  in  pecuniary 
difficulties.  He  made  a  very  large  claim.  This  was  ultimately 
settled,  and  he  forthwith  went  into  the  country  for  change  of  air. 
He  returned  home  in  a  fortnight  looking  and  saying  that  he  was  in 
every  respect  perfectly  well.  He  resumed  his  work  at  once,  and 
continued  it  for  many  years  after  the  accident.  Could  recovery 
in  this  case  have  taken  place  in  so  short  a  time  had  the  symp- 
toms and  complaints  not  been  purposely  induced,  maintained,  or 
fabricated  ?  Is  it  not  as  well-nigh  certain  as  can  be  that  had 
not  the  prospect  of  compensation  held  out  the  temptation  to  this 
man  to  make  the  very  worst  of  his  injury,  with  the  hope  of 
pecuniary  profit  to  himself,  he  would  have  been  laid  up  for  not 
more  than  two  or  three  days  ?  And  yet  he  was  an  invalid  for 
eleven  months — a  wretched  picture,  indeed,  of  induced  malaise ; 
but  a  malingerer  nevertheless,  purposely  maintaining  his  condition 
in  order  to  increase  his  claim. 


MALINGERING.  II7 

Case  29. — Physical  injuries — Nervous  shock — Early  recovery. — 
Two  cases  out  of  the  same  accident,  those  of  a  father  and  son, 
may  be  compared.  The  father,  a  man  in  a  small  way  of  busi- 
ness, aged  fifty-eight,  was  seen  in  bed  at  an  hotel  in  a  provincial 
town  the  morning  after  a  bad  collision.  He  was  unable  to  give 
any  account  of  the  accident,  having  been  stunned  by  a  blow 
which  had  closed  both  his  eyes.  He  had  also  a  broken  rib,  and 
was  much  bruised  elsewhere.  He  had  had  about  two  hours' 
sleep  in  the  night,  had  rallied,  and  felt  better.  A  week  later  he 
was  still  mending,  and  although  he  was  pulled  down  by  rather 
severe  epistaxis,  he  was  able  in  twenty-four  days  to  be  moved 
home.  There  he  continued  to  go  on  well.  In  six  months  his 
claim  was  arranged  without  trouble  for  a  reasonable  sum,  and 
when  I  saw  him  three  months  afterwards  he  looked  and  said  he 
was  perfectly  well. 

Case  30. — Slight  injuries — Prolonged  complaints — No  evideyice 
of  ill-health. — The  son,  a  strong  and  powerful  man,  aged  twenty- 
four,  a  messenger  by  occupation,  was  not  stunned,  and  was  able 
to  help  his  father  to  the  hotel.  When  seen  on  the  following 
day  he  said  he  had  had  a  good  night,  but  that  he  felt  rather 
shaken.  He  had  a  slight  bruise  on  the  right  knee,  and  a  simple 
fracture  of  the  third  metacarpal  bone  of  the  left  hand.  A  week 
later,  to  my  astonishment,  I  found  him  still  in  bed,  but  neither 
in  aspect,  temperature,  nor  pulse  was  there  anytliing  abnormal, 
and  he  had  been  able  to  eat  and  enjoy,  from  the  very  morning 
after  the  accident,  three  meat  meals  a  day.  He  was  ordered  up, 
and  he  would  have  been  sent  home  immediately  had  not  the 
illness  of  his  father  obliged  him  to  stay.  Wlien  he  got  home  he 
at  once,  by  the  aid  of  a  litigious  lawyer,  took  steps  to  make  an 
exorbitant  claim  against  the  railway  company.  Two  months 
after  his  retvn^n  home  he  had  not  yet  resumed  his  work.  The 
reasons  assigned  for  this  were  that  he  had  giddiness  and  pain  in 
the  head,  that  his  memory  was  bad  and  his  sleep  disturbed  by 
dreams  of  the  accident,  that  he  was  very  weak  and  incapable  of 
work,  and  that  he  could  not  trust  himself  to  apply  himself  to 
anything.  His  knee  and  hand  were  still  in  bandages,  the  arm 
being  carried  in  a  sling.  I  failed  to  discover  any  sign  whatever 
of  ill-health  about  him.  Thus  he  continued  to  complain  and  to 
live  in  idleness  until  ten  months  had  flown,  when  a  jury  awarded 
him  a  sum  in  reasonable  compensation,  or  about  one-fourth  of 
that  which  he  had  demanded.  He  was  then  to  every  appearance 
and  test  in  perfect  health,  though  still  complaining  as  before. 


Il8  RAILWAY  INJURIES. 

Case  31, — Slight  slioch — Prolonged  complahits — Absence  of  all 
symptoms. — A  man,  aged  forty-two,  strong  and  healthy,  was  in 
two  slight  collisions.  In  the  first  there  was  no  evidence  or 
history  of  his  having  received  any  blow  or  injury.  He  stated, 
however,  that  the  day  after  the  accident  he  felt  weak,  ached  all 
over,  and  had  pains  in  the  loins  and  legs  as  if  he  had  a  cold. 
No  amendment  took  place,  nor  had  he  indeed  been  free  from 
suffering  up  to  the  time  when  I  saw  him  eight  months  after- 
wards. He  then  complained  of  weakness  and  fatigue,  of  bad 
sleep  and  loss  of  memory,  and  of  such  great  nervousness  that  the 
whistle  of  an  engine  or  the  sound  of  a  train  threw  him  into  a 
state  of  excitement.  His  manner  was  whining,  and  he  made 
several  attempts  to  cry.  His  medical  attendant  had  never  found 
any  evidence  of  illness  beyond  the  statements  made  to  him  by 
the  man  himself.  Neither  in  his  general  aspect,  nor  in  the  action 
of  any  one  of  his  organs,  could  any  sign  of  ill-health  be  dis- 
covered. He  abstained  from  work  for  fifteen  months,  and  at 
once  resumed  it  on  the  settlement  of  his  claim,  then  grown  in 
size  through  length  of  alleged  suffering  and  loss.  Two  years 
went  by,  and  he  was  fortunate  enough  to  be  in  a  second  collision 
in  which  he  received  a  triiling  bruise  on  one  leg.  He  at  once 
abstained  from  work,  placed  himself  under  medical  care,  made 
precisely  the  same  complaints  as  before,  and  presented  as  little 
evidence  of  ill-health.  Again  there  were  months  of  idleness,  and 
again  on  tlie  settlement  of  claim  immediate  recovery,  and  return 
to  work. 

Further  examples  of  this  particular  kind  of  malingering  are 
hardly  necessary,  although  many  might  have  been  given,  which, 
with  insimificant  variations,  have  followed  the  same  course. 
They  are  often  styled  cases  of  "  shock  to  the  nervous  system." 
Their  chief  characteristic  is  the  obscurity,  the  intangibility,  and 
entire  subjectivity  of  all  the  symptoms  and  complaints  which 
disappear  at  a  particular  moment.  They  are  not  rarely  accom- 
panied by  some  manifest  disturbance  of  health,  which  is  induced 
by  the  mode  of  life  to  which  the  individual  restricts  himself. 
Can  want  of  proper  occupation  and  exercise  act  otherwise  than 
harmfully  even  to  a  healthy  man  ?  Sleep  becomes  unsound,  the 
bowels  are  sluggish,  appetite  fails,  the  glow  of  healthy  energy 
and  vitality  is  lost,  and  there  is  no  longer  the  picture  of  per- 
fect health.  Be  the  bodily  derangement  thereby  great  or  lie  it 
infinitesimally  small,  health  and  vigour  are  restored,  and  work  is 
resumed,  as  soon  as  it  is  no  longer  incumbent  on  the  man  to 
appear  ill  and  to  remain  idle,  and  when  the  requisite  effort  to 


MALINGERING.  II9 

return  to  a  natural  mode  of  life  is  once  more  allowed.  The 
man  has  nursed  himself  into  a  state  of  illness,  and  has  thereby- 
generated  a  condition  of  spurious  nervous  shock,  and  if  he  only 
has  the  prudence  to  complain  of  his  back,  his  case  becomes  a 
grave  one  of  so-called  concussion  of  the  spine. 


12.  Examples  of  this  induced  illness  are  far  from  uncommon,  Relative 
and  the  very  fact  that  the  patient   seems  really  ill  places  an  objecUve 
additional  difficulty  in  the  way  of  an  accurate  diagnosis  of  the  s|fb"ec^t"ve 
cause.      Apart   from    the    necessity   of    learning   what   was   the  symptoms, 
precise  nature  of  the  accident,  and  how  the  man  was  hurt,  it  is 
very  essential  to  know  how  he  passes  his  time,  and  what  are  his 
habits  and  occupations  day  by  day.      It  is  of  paramount  import- 
ance to  separate  objective  signs  from  subjective  symptoms.      The 
absence  of  signs,  and  the  presence  of  subjective  symptoms  alone, 
may  fairly  warrant  a  suspicion,  which  ought  to  entail  the  most 
careful  inquiry  into  all  the  circumstances  of  the  case.      Why  is 
that  man  in  bed  ?  why  does  he  stay  for  weeks  indoors  ?  why  is 
he  taking  hardly  any  food  ?  why  is  he  pale  and  thin  ?  why  does 
he  sweat  ? — questions  such  as  these  the  surgeon  should  ask  him- 
self, and  he  should  not  rest  satisfied  with  a  tacit  belief  in  what 
he  hears  or  sees. 

In  other  cases  there  may  be  a  combination  of  obscure  subjec- 
tive symptoms  and  of  precise  objective  signs  which  throw  mutual 
light  upon  each  other,  or  wliich  perchance  may  tend  to  make  a 
diagnosis  still  more  difficult. 

Case  32. — No  ivjury — Prolonged  complaints — Immediate  re- 
covery on  settlement. — A  traveller  by  occupation,  aged  fifty-three, 
out  of  employ,  took  to  his  bed  and  called  in  a  doctor  three  days 
after  a  most  trifling  bump  against  the  stop-blocks  in  a  station. 
He  made  the  usual  complaints  of  pain,  of  shock  to  his  nervous 
system,  dimness  of  vision,  loss  of  memory,  and  the  like,  but  there 
was  never  any  sign  whatever  of  ill-health  or  functional  derange- 
ment beyond  what  might  be  fairly  attributed  to  some  atheroma 
of  the  aorta.  The  extravagance  of  his  language  and  his  exag- 
gerated estimate  of  all  his  complaints  were  in  themselves  enough 
to  raise  suspicion  as  to  their  reality.  Objectively  he  complained 
of  loss  of  power  in  the  right  arm  with  stiffness  of  tlie  right  elbow, 
and  of  a  putty-like  sensation  of  the  left  leg  below  the  knee  and 
stiffness  of  that  joint.  In  all  ordinary  movements,  such  as  un- 
dressing or  helping  himself  out  of  bed,  he  used  the  right  arm 


I20  RAILWAY    INJURIES. 

qviite  as  much  as  the  left.  It  presented  no  difference  from  its 
fellow,  though  when  speaking  to  him  about  it  he  always  held  it 
against  his  side.  He  resisted  with  great  force  when  you  attempted 
to  bend  it,  and  he  called  out  loudly,  as  if  from  pain,  when  you 
touched  the  arm,  however  lightly,  about  the  elbow-joint.  His 
left  leg  showed  no  physical  signs  of  injury  or  disease  about  the 
knee.  Held  usually  rigid  and  stiff,  he  resisted  any  attempts  at 
passive  flexion.  Flexion  to  the  slightest  degree,  he  said,  caused 
him  great  agony,  although  his  face  showed  no  sign  of  suffering. 
On  another  occasion  he  complained  of  excessive  hypera^sthesia 
of  the  left  knee,  however  gently  you  touched  it  with  the  finger, 
although  he  pulled  up  and  put  down  his  trousers  over  it  with 
perfect  composure.  He  complained  of  great  agony  in  his  bladder, 
although  he  only  passed  water  at  natural  intervals  and  in  proper 
quantity,  and  he  could  hold  it  for  six,  eight,  or  even  twelve  hours. 
He  stayed  in  bed  about  ten  weeks,  and  took,  as  he  admitted, 
hardly  any  food.  Towards  the  close  of  the  twelve  months,  during 
which  this  state  of  things  went  on,  he  had  become  somewhat 
weak  and  thin.  Quite  early  he  had  made  an  exorbitant  claim, 
and  tlie  natural  result  was  litigation.  While  waiting  for  his 
action  to  come  on  the  man  was  to  be  seen  walking  about  West- 
minster Hall  with  the  lame  stiff  leg,  and  the  flexed  arm  held 
rigid  to  his  side.  His  action  over,  he  there  and  then  resumed  a 
natural  gait,  all  trace  of  lameness  having  passed  away.  Were 
the  subjective  symptoms  less  unreal  than  those  which  so  quickly 
vanished  ? 

Case  33. — Purposive  vomiting — Immediate  recovery  on  settle- 
ment.— Now  let  us  take  another  case  which  offers,  perhaps, 
greater  difficulties  in  diagnosis.  Omitting  details  of  the  usual 
subjective  ailments,  the  objective  signs  of  illness  were  frequent 
vomiting,  and  such  apparent  weakness  of  the  legs  that  walking 
was  only  slow  and  laboured.  The  surgeon  who  saw  the  man  on  be- 
half of  the  railway  company,  and  who  gave  me  the  history  of  this 
case,  felt  sure  from  all  he  saw  that  the  symptoms  were  far  from 
genuine,  and  among  them  that  the  vomiting  itself  was  a  deliberate 
volitional  act.  It  was,  to  say  the  least,  a  suspicious  feature  in 
the  case  that  the  patient  had  been  seen,  when  he  thought  he  was 
out  of  sight,  to  start  off  at  a  natural  pace,  swinging  the  stick 
on  which  he  had  been  compelled  to  lean  only  a  moment  before. 
Knowing  all  this,  the  surgeon  felt  it  his  duty  to  tell  the  private 
medical  attendant  what  he  thought  about  the  case,  and  he  resolved 
to  do  so  on  the  next  occasion  wdien  they  were  to  meet  at  the 


MALINGERING.  I  2  I 

doctor's  house  to  see  the  patient.  Having  told  his  opinion,  the 
doctor  pointed  out  the  utter  impossibiHty,  in  his  behef,  of  so 
grave  a  symptom  being  vohmtary,  and  took  him  into  his  own 
yard  to  show  how  the  man  had  vomited  since  he  came  to  his 
house  not  long  before.  The  surgeon's  opinion,  nevertheless, 
remained  unchanged,  and  the  result  of  the  case  justified  and  con- 
firmed it.  Infirm  of  body  and  mind,  incapable  of  work,  vomiting 
up  to  the  day  of  his  action  for  damages,  the  man  immediately 
recovered  when  litigation  was  over. 

In  the  case  of  a  horse-dealer  who  rapidly  wasted  and  became 
extremely  ill,  and  in  whom  the  most  prominent  symptom  was 
sweating,  the  man  subsequently  acknowledged,  when  his  speedy 
recovery  after  compensation  excited  his  doctor's  surprise,  that  he 
had  deliberately  sweated  himself  by  violent  exercise  in  thick  cloth- 
ing in  order  to  reduce  his  weight  and  size. 

To  those  who  have  never  seen  such  cases  it  may  appear  almost 
incredible  that  symptoms  like  these  can  be  volitional  and  unreal.^ 
Take,  liowever,  into  consideration  every  circumstance  and  feature 
of  the  case ;  learn  what  has  been  the  original  injury ;  recognise 
how  singular  it  is  that  a  symptom,  alarming  in  itself,  should  be  by 
itself  independent,  and  without  ill  result ;  remember  how  powerful 
is  the  motive  for  deception ;  inquire  what  steps  the  patient  is 
taking  to  gain  the  desired  end,  and  there  are  the  means,  if 
you  will  only  use  them,  of  arriving  at  a  right  diagnosis. 


13.   The  character  of  the  original  accident  and  injury  is  far  too  import- 

(iIlC6  of  iX 

often  forgotten  in  the  later  examination  of  these  cases,  and  a  correct 
trifling  bump  is  magnified  into  a  serious  collision.  history 

Case  34. — Slight  mjury — Gross  exaggeration — Rapid  recovery 
after  settlement. — A  man  received  an  altogether  trivial  blow  on 
his  side,  from  the  manner  in  which  he  happened  to  be  sitting, 
when  the  train  attached  a  carriage  at  a  station,  and  the  so-called 
accident  ultimately  became  a  severe  collision,  in  which  the  train 
had  been  backed  into  a  carriage  at  the  great  speed  acquired  in 
a  run  of  half  a  mile,  with  a  crash  like  thunder.  This  was  the 
story  upon  which  those  were  asked  to  form  an  opinion  who  were 
called  in  to  see  him,  wdien,  after  several  months,  he  had  nursed 
himself  into  a  condition  of  much  weakness,  nervousness,  and 
malaise,  and  when  his   very  obvious    illness  seemed   almost  to 

1  Some  remarkable  instances  of  factitious  vomiting  are  recorded  by  Gavin,  op,  cit., 
p.  256,  et  scq. 


122  EAILWAY    INJUIilES. 

demand  a  serious  accident  as  its  cause.  It  is  very  natural  that 
there  should  be  some  distrust  in  the  statements  of  railway 
servants  as  to  the  precise  violence  of  a  collision  or  other  accident. 
The  absolute  and  unvq.rnished  truth  as  to  the  real  severity  of  the 
accident  was  known,  at  any  rate,  in  this  case,  and  was  somewhat 
different  from  the  alarming  catastrophe  to  which  testimony  was 
borne  in  a  court  of  law,  where  a  jury  is  supposed  to  get  at  the 
actual  facts.  A  large  sum  of  money  was  awarded  to  this  man 
in  compensation,  and  he  instantly  invested  it  in  a  business  which 
he  proceeded  forthwith  to  carry  on  himself,  with  all  the  appear- 
ances of  perfect  health,  and  without  any  further  need  for  medical 
treatment. 

Case  35. — Simulation  of  spinal  injury  and  false  statement  as  to 
accident. — A  highly  respectable  frequenter  of  the  turf  took  to  his 
bed  after  a  very  trilling  collision.  He  was  unable  to  give  any 
account  of  the  accident,  having  been  knocked  insensible,  and  been 
carried  in  an  unconscious  state  to  the  waiting-room  of  a  station, 
distant  a  quarter  of  a  mile.  He  had,  however,  been  able  to 
make  a  long  journey  home  two  days  after  the  accident,  that  is  to 
say,  when  the  races  were  over ;  and  he  at  once  took  to  his  bed. 
I  saw  him  on  the  eighth  day.  When  asked  what  he  complained 
of,  he  answered  with  ready  assurance,  "  Shock  to  the  nervous 
system,  and  injury  to  my  spine."  He  could  give  no  other 
account  than  this  of  his  complaints,  except  that  he  was  wholly 
unable  to  get  out  of  bed.  Examination,  which  failed  to  discover 
the  slightest  trace  of  injury  or  constitutional  disturbance,  acci- 
dently  revealed  that  this  gentleman  had  a  chancre ;  and  the 
discovery  afforded  the  excuse  for  promptly  ordering  him  to  get 
up  and  walk.  His  doctor  had  regarded  it  as  a  case  of  very 
serious  spinal  injury.  The  claim  was  forthwith  settled  for  a 
small  sum. 

Case  36. — Alleged  spinal  injury — Gross  imposture. — This  same 
man  subsequently  appeared  as  a  witness  on  behalf  of  a  friend, 
who  had  brought  an  action  for  damages  for  a  like  alleged  injury 
in  the  same  accident.  He  was  a  most  valuable  witness,  for  he 
swore  that  he  and  another  man  had  carried  their  friend,  then 
perfectly  unconscious,  from  the  scene  of  the  accident  to  the  wait- 
ing-room at  the  station.  The  friend,  an  even  more  outrageous 
impostor,  had  had  a  slight  bruise  on  one  hip.  He  also  finished 
his  mission  at  the  races,  came  home,  and  at  once  took  to  his  bed, 
complaining  of  his  spine.      "  The  pain  in   his   back,"  so  ran  my 


MALINGERING.  I  23 

report  some  weeks  after  the  accident,  "is  so  bad  that  a  longer 
stay  than  half-an-hour  out  of  bed  is,  he  says,  ahnost  more  than 
he  can  bear.  His  pnlse  is  perfectly  tranquil,  his  temperature 
normal,  his  aspect  not  that  of  ill-health  or  urgent  suffering,  and 
the  appetite  and  bodily  functions  are  as  good  as  can  be  expected 
in  any  one  who  has  so  long  been  without  appetite  and  indoors. 
It  is  my  conviction  that  he  is  grossly  exaggerating  his  symptoms 
and  complaints.  There  is  no  evidence  whatever  of  injury  to  his 
nerve-centres,  either  cerebral  or  spinal ;  nor  is  there  any  ground 
for  believing  that  there  is  any  real  tenderness  of  his  spine,  for 
wherever  I  touched  him,  whether  on  the  spine  itself,  on  the 
muscles  near  it,  or  on  the  ribs  far  away  from  it,  there  was  the 
same  unreal  hypersensitiveness  and  manifestation  of  suffering. 
That  he  has  some  pain  here  and  there  is  quite  probable  ;  but 
there  is  no  disease  such  as  to  call  for  his  stay  in  bed  or  in  the 
house  for  another  day."  It  need  hardly  be  said  that  litigation 
ended  this  case,  which  was  a  highly  profitable  one  for  the 
lawyers. 

Three  years  afterwards  it  was  learned  from  this  man  himself 
— perhaps  in  the  circumstances  the  least  trustworthy  source  of 
information — that  his  case  from  beginning  to  end  was  a  fraud, 
that  he  was  never  hurt  at  all,  and  that  no  amount  of  money 
would  induce  him  to  go  through  such  a  course  of  illness  and 
confinement  again,  or  to  endure  such  suffering  as  he  had  at  the 
hands  of  those  who  deemed  it  necessary  to  run  pins  into  his  legs 
and  to  apply  the  "  electric  test "  to  measure  his  assumed  insensi- 
bility. I  venture  to  say  that  no  such  "  tests  "  were  ever  needed, 
and  that  their  tendency  was  only  to  confuse  and  obscure  what 
ought  to  have  been  sufficiently  obvious  to  every  one  who  saw  the 
patient.  How  fallacious  they  are,  and  in  this  case  were,  it  is 
superfluous  to  point  out,  and  yet  they  were  solemnly  given  in 
evidence  in  court  as  conclusive  signs  of  the  serious  nature  of  the 
man's  disease. 


luimeses. 


14.  Then,  again,  there  is  a  class  of  cases  where  the  patient  The  nenro- 
may  simulate  the  mimicries  of  disease.  There  are  none  in  which 
it  is  more  imperative  to  know  something  of  the  patient's  history, 
of  his  previous  health,  his  position  in  life,  his  condition  imme- 
diately or  soon  after  the  accident,  the  nature  and  extent  of  the 
accident  itself,  and  the  whole  aspect  of  the  case  from  beginning 
to  end. 


124  RAILWAY    INJURIES. 

Case  37. — Slight  injury — Prolonged  simulation  and  rapid 
recovery  after  settlement. — T.  J.,  aged  forty-three,  was  in  a  slight 
accident,  in  which  he  had  a  small  bruise  on  one  cheek  and  also 
at  the  back  of  the  head.  He  was  seen  shortly  after  the  accident, 
but  there  was  no  sign  either  of  injury,  beyond  the  bruises  named, 
or  of  constitutional  disturbance.  In  about  ten  days  he  was 
"  taken  worse,"  but  in  no  very  definite  way.  He  gave  notice  of 
a  claim,  and  then  began  to  complain  indefinitely  of  pain  in  the 
back,  of  pain  in  the  legs,  and  oppression  in  the  head.  There 
was  still,  however,  no  e\ddence  of  illness  or  constitutional  dis- 
turbance. He  continued  to  get  worse,  and  two  months  after  the 
accident  took  to  bed.  He  had  not  been  in  bed  many  days  when 
he  had  a  "  bilious  attack,"  with  constipation  and  vomiting.  A 
month  elapsed,  and  he  then  was  seized,  so  he  said,  with  a  "  con- 
vulsive attack  "  in  which  his  legs  were  drawn  up,  and  he  was  very 
violent.  From  that  time  forward  he  professed  to  be  troubled 
with  "  contractions  of  the  limbs  and  severe  pain  in  the  legs, 
aggravated  by  attempting  to  sit  up."  He  also  complained  of 
queer  sensations  all  over,  numbness  in  his  tongue,  for  example, 
creepings  in  his  legs,  tenderness  of  the  pahns  of  the  hands. 
Pulse  and  temperature  alike  remained  perfectly  normal.  Five 
months  after  the  accident  he  was  still  in  bed  complaining  of 
great  pain  in  his  back,  of  pain  and  tenderness  in  the  legs,  and  of 
inability  to  stand  if  he  got  out  of  bed.  He  held  his  hands  out 
somewhat  in  the  position  of  tetany,  but  the  contraction  imme- 
diately disappeared  when  he  ceased  to  direct  attention  to  it. 
Although  when  he  first  got  out  of  bed  he  allowed  his  legs  to  slip 
away  and  himself  to  fall,  he  only  had  to  be  engaged  in  conversa- 
tion to  show  that  his  legs  were  amply  strong  enough  to  support 
his  whole  body.  There  were  no  objective  signs  whatever  of 
paralysis,  nor  was  any  illness  to  be  discovered  about  him,  except 
such  as  might  fairly  be  accounted  for  by  his  having  been  in 
bed  for  three  months.  Thus  his  muscles  were  somewhat  flabby, 
his  face  was  pale,  and  his  tongue  was  furred.  Temperature  and 
pulse,  however,  were  normal ;  his  pupils  were  of  healthy  size  ; 
his  mind  was  perfectly  clear.  So  his  state  continued  until  the 
close  of  a  year,  when  his  claim  was  settled  by  compromise  on  the 
verge  of  litigation,  it  being  held  that  he  had  received  a  very 
severe  injury  to  his  nervous  system,  that  prospect  of  recovery 
was  very  small,  and  that  it  was  wholly  impossible  for  him  to 
appear  and  give  evidence  as  plaintiff  at  the  action.  His  evidence 
was  indeed  taken  by  commission,  the  man  being  quite  unfit  to 
leave  his  bed.      He   had  made  a  very  large  claim — not  the  first 


MALINGERING.  12$ 

in  liis  life,  for  he  had  received  compensation  for  alleged  injuries 
some  years  before.  Mark  the  sequel.  In  ten  days  he  was  out 
of  doors,  in  a  fortnight  he  went  away  for  change  of  air,  and  in 
two  months  he  resumed  his  usual  work.  He  has  continued  at 
work  since  that  time  in  the  enjoyment  of  good  health. 


15.  In  instances  such  as  this  it  is  often  difficult,  and  well-  The  co- 
nigh  impossible,  to  say  whether  the  condition  is  one  dependent  on  of  nervous 
genuine  neurotic  disturbance  or  is  altogether  feigned.     And  the  ^erange- 

"  ,  .  nients. 

difficulty  is  largely  due  to  the  fact,  that  a  disorder  of  this  char- 
acter may  be  more  or  less  under  the  control  of  the  patient  him- 
self, as  it  has  been  pointed  out  on  a  previous  page.  It  is  therefore 
of  the  greatest  importance  to  search  for  some  symptom,  which 
may  rightly  be  placed  in  the  category  of  hysterical  or  emotional 
disorders.  Every  objective  sign  that  you  discover  may  be  under 
the  patient's  own  control,  may  be  a  physical  condition  altogether 
assumed,  and  the  clue  to  the  whole  case  may  be  entirely  wanting 
until  some  symptom  be  found,  which  is  outside  and  beyond  his 
voluntary  control,  or  is  even  unknown  to  him.  Analgesia  or 
anaesthesia,  for  example,  may  form  the  only  indication  of  the  real 
character  of  the  disease.  Dr.  J.  Putnam  has  admirably  dealt 
with  this  aspect  of  the  subject  in  a  paper  on  "  Eecent  investi- 
gations into  the  pathology  of  so-called  concussion  of  the  spine, 
with  cases  illustrating  the  importance  of  seeking  for  evidence  of 
typical  hysteria  in  the  chronic  as  well  as  in  the  acute  stages  of 
the  disease "  {Boston  Med.  and  Surg.  Journcd,  vol.  cix.,  Sept.  6, 
1883).  After  recording  two  cases  of  hemiana?sthesia  in  men, 
he  says  that  this  is  a  symptom  which  shows  that  the  nervous 
system  has,  in  all  probability,  been  subjected  at  some  past 
time  to  a  considerable  perturbing  influence,  and  its  presence  or 
absence  might  prove  a  welcome  aid  to  diagnosis.  A  symptom 
of  this  kind  may  throw  light  upon  a  case,  but  it  does  not 
necessarily  exclude  a  considerable  degree  of  wilful  exaggeration 
or  even  downright  fraud  in  the  other  symptoms  and  signs.  A 
deliberate  impostor,  for  example,  lost  all  tactile  sensation  over 
the  mucous  surface  of  his  nares,  a  symptom  which  it  would  surely 
be  impossible  to  feign,  and  which  was  a  clear  evidence  that  some 
effect  had  been  wrought,  somehow  and  somewhere,  upon  the 
nervous  system.  Eegions  of  antesthesia,  moreover,  which  follow 
no  recognised  anatomical  distribution  of  nerves,  say  of  one  leg 
up  to  a  precise  limit  at  the  knee  or  half  way  up  the  thigh,  are 
occasionally  present,  and  it  is  obviously  very  desirable  that  no 


126 


RAILWAY    INJURIES. 


symptom  of  the  kind  should  be  overlooked  in  the  examination 
of  those  cases  where  absence  of  the  ordinary  indications  of  illness 
and  disease  may  suggest  malingering.  Marvellous  and  deeply 
interesting  are  such  manifestations  of  the  close  interdependence 
of  mental  and  bodily  states,  and,  freed  from  the  incubus  of  com- 
pensation and  the  temptation  to  malinger,  it  may  be  said  of  the 
nervous  consequences  of  railway  accidents,  that  they  are  not 
unworthy  of  the  study  of  the  ablest  and  most  pliilosophical  men 
in  the  profession. 


The 
general 
conduct 
and  bear- 
ing of  ma- 
lingerers. 


16.  We  have  nothing  to  do  here  with  the  pathology  of  morals, 
nor  need  we  gauge  the  different  degrees  of  moral  obliquity  in 
undoubted  feigning  and  assumption  of  disease,  and  in  wilful 
exaggeration  of  real  conditions  as  a  means  to  compass  some  aim 
in  view.  Were  all  cases  of  simple  exaggeration  to  be  included 
under  the  same  head  as  cases  of  fictitious  and  feigned  disease, 
the  material  would  from  very  bulk  become  unmanageable.  If, 
as  it  has  been  said,  the  motive  be  so  strong  and  so  prevailing,  it 
is  natural  and  only  human  that  exaggeration  should  be  met  with 
in  a  large  proportion  of  the  persons  injured  in  railway  accidents. 
But,  on  the  other  hand,  it  must  be  remembered  that  exaggeration 
may  not  be,  nay,  very  often  is  not,  altogether  wilful  or  assumed. 
Exaggeration  is  the  very  essence  of  many  of  those  emotional  or 
hysterical  disorders,  which  are  so  common  in  both  sexes  after 
the  shock  of  collisions.  Here  it  may  be  an  idiosyncrasy  of  the 
individual ;  there  it  may  be  the  outcome  of  mental  disturbance 
from  the  fright  and  alarm  amid  which  the  injury  was  received. 
It  is  only  by  a  consideration  of  every  feature  and  aspect  of  the 
case — clinical,  pathological,  social,  and  moral  —  that  you  can 
rightlv  estimate  the  kind  of  exaofc^eration  or  malino;erinQj  with 
which  you  have  to  do. 


CHAPTER  VIII. 

THE   MEDICO-LEGAL   ASPECT   OP   RAILWAY 
INJURIES. 

Summary. — I.  Compensation  for  injuries,  and  its  influence  upon  them. — 2.  Suspense 
and  unsettlement  of  mind. — 3.  Danger  of  leading  questions. — 4.  The  use  and 
abuse  of  instruments  of  precision. —  5-  Electrical  examinations. — 6.  Medical 
evidence  in  courts  of  law. 

1.   It    may    not    be    altogether   without    advantage    if   a   few  Compensa- 
concluding  remarks   are    made  upon  those  circumstances  which  j,\*juries 
are   special    in,    and   peculiar   to,   the    class   of  cases    considered  ^'^'^  ^^^ '"' 

^  '  .  '  .  fluence 

in  this  book,  and  which  are  commonly  absent  from  the  ordinary  upon  them, 
accidents  and  diseases  met  with  in  everyday  practice.  Every 
case  of  railway  injury  is  more  or  less  the  subject  of  medico-legal 
inquiry,  for  the  extent  of  the  injury  itself  and  the  loss  which 
it  entails  have  to  be  estimated,  as  far  as  possible,  by  a  money 
value  which  is  paid  as  compensation,  and  difficulties  or  disputes, 
which  may  arise  in  arriving  at  this  estimate,  may  occasionally 
entail  an  appeal  to  a  court  and  jury  by  process  of  litigation.  All 
this  may  very  materially  modify  the  clinical  aspect  of  individual 
cases  and  symptoms,  and  no  right  estimate  of  any  case  can  be 
made  if  these  circumstances  are  ignored. 

At  first  sight,  perhaps,  it  is  not  very  clear  why  compensation 
should  be  an  element  of  importance  in  the  course  and  history  of 
the  spinal  and  other  injuries  received  in  railway  collisions.  Let 
us  picture  for  a  moment  the  change  which  would  come  over  our 
hospital  patients  if  a  pecuniary  value  were  to  be  placed  upon 
every  injury  they  sustained.  The  probability  that  many  of  them 
would  see  only  the  worst  side  of  their  ailments,  that  they  would 
lay  undue  stress  upon  their  pains,  and  would  exaggerate  the  term 
of  prospective  disablement  from  work  is  at  once  obvious,  were 
these  to  have  a  place  in  calculating  the  money- worth  of  the  injury 
received.  When  a  man  has  been  prostrated  by  illness  or  injury, 
and  convalescence  has  at  length  set  in,  we  know  that  he  must 
make  some  voluntary  effort  to  regain  his  former  activity  both  of 

127 


128  RAILWAY    INJURIES. 

body  and  mind.  His  habit  of  work  and  the  daily  routine  of  his 
life  have  both  been  interrupted,  and  it  depends  very  largely  upon 
his  own  efforts  how  soon  and  how  successfully  the  thread  shall 
be  taken  up  again.  It  is  clearly  to  his  interest  to  get  well  as 
soon  as  he  can,  and  exj)erience  tells  us  that  so  keen  is  the  desire 
for  recovery  and  renewed  activity,  that  many  a  man's  restoration 
to  perfect  health  is  often  retarded  by  his  having  begun  work  too 
soon.  Suppose,  however,  that  compensation  is  to  be  awarded  for 
every  ache  and  pain,  and  for  every  day  that  he  is  absent  from 
his  work,  it  is  only  natural  that  the  keenness  of  his  desire  to 
resume  his  work  should  be  very  much  diminished.  If  our 
hospital  patients  were  to  be  compensated  we  may  be  sure  that 
the  features  of  many  a  case  would  be  completely  changed,  and 
that  the  whole  clinical  history  of  disease  would  wear  a  very 
different  aspect  from  that  which  is  usually  seen.  And  changed 
for  this  reason,  that  compensation  acts  as  a  let  and  hindrance 
to  the  natural  and  very  necessary  effort,  which  each  person  must 
make  for  himself  towards  convalescence  and  resumption  of  work. 
It  may  do  so  quite  unconsciously,  for  the  knowledge  that  compen- 
sation will  certainly  be  paid  him  for  the  injuries  sustained  in  a  rail- 
way accident  tends  from  the  first  day  of  illness  to  give  a  tone  to 
his  feelings  and  to  affect  his  own  impressions  of  the  sufferings 
which  he  may  have  to  undergo.  He  is  less  likely  to  take  a  hope- 
ful view  of  the  future,  is  more  prone  to  be  despondent  about  the 
prospects  of  his  recovery,  and  insomuch  will  his  own  personal 
efforts  be  weakened.  It  is  well  that  this  matter  of  compensation 
has  no  place  in  everyday  hospital  practice,  and  you  will  always 
do  wisely,  in  endeavouring  to  form  an  estimate  of  the  cases  which 
involve  medico-legal  inquiry,  to  revert  to  your  hospital  experiences, 
and  to  recall  the  usual  history  of  your  hospital  patients,  both  as  to 
suffering  and  disablement,  and  the  prospects  of  recovery. 

It  is  not  sought  here  to  establish  any  doctrine  so  absurd  as 
that  settlement  of  claim  can  of  itself  be  a  curative  agent,  in  the 
sense  that  it  can  hasten  the  setting  of  a  fracture,  remove  the 
pain  which  is  an  inseparable  concomitant  of  sprain  of  the  ver- 
tebral muscles  and  ligaments,  or  restore  the  nervous  tone  which 
has  been  upset  by  the  shock  of  a  collision.  The  natural  forces 
here,  as  elsewhere,  tend  to  restoration  of  health  ;  and  recovery  is, 
happily,  as  perfect  after  the  injuries  commonly  received  in  colli- 
sions, as  it  is  after  any  other  kind  of  injury  which  the  surgeon 
may  be  called  upon  to  treat.  There  is  this  difference,  however, 
and  it  is  a  great  one,  that  when  the  immediate  effects  of  injury 
are  passing  away,  and  there  is  every  sign  that  convalescence  has 


MEDICO-LEGAL    ASPECT    OF    RAILWAY    INJUIIIES.         I  29 

set  in,  compensation  holds  out  an  inducement  to  the  patient  not 
to  make  the  requisite  effort  to  resume  his  work  and  his  ordinary 
avocations,  which  are  in  themselves  the  best  means  of  crownincr 
the  period  of  convalescence  and  of  restoration  to  health.  Had 
the  ordinary  injuries  of  hospital  and  everyday  practice  to  con- 
tend with  this  element,  convalescence  would  be  very  much 
hampered  and  prolonged,  while  if  there  was  no  question  of  com- 
pensation to  enter  into  the  contemplation  of  railway  injuries,  these 
in  their  turn  would  be  recovered  from  with  no  less  certainty  and 
with  much  greater  promptitude. 


2.  Human  nature  would  not  be  what  it  is  if  compensation  did  Suspense 
not  exercise  this  influence  in  delaying  recovery,  and  it  may  do  settlement 
so  even  in  the  case  of  those  who  have  been  really  hurt,  and  who  "^  """f^- 
are  genuinely  anxious  to  get  well.  Too  much  stress  ought  not, 
however,  to  be  laid  upon  compensation  itself,  for  very  often  it  is 
the  unsettlement  of  mind  incidental  to  the  arrangement  of  the 
claim,  rather  than  the  prospect  of  pecuniary  gain,  which  is 
exerting  an  injurious  influence.  Happily  the  medical  man  is  not 
often  called  upon  to  determine  whether  his  patient  is  consciously 
making  use  of  his  injuries  for  the  purpose  of  profit,  or  is  the 
unconscious  victim  of  this  mental  unsettlement,  but  he  very 
frequently  has  to  determine  whether  it  is  likely  to  be  for  his  good 
that  his  claim  should  be  arranged.  Suppose,  for  example,  that 
several  months  have  elapsed  since  the  accident,  and  that  while 
there  are  no  fresh  indications  of  injury  the  symptoms  neverthe- 
less continue  without  amelioration,  experience  shows  that  settle- 
ment of  claim  is,  in  all  probability,  the  one  and  only  thing  required 
to  start  the  process  of  convalescence  with  reasonable  hope  of  speedy 
recovery.  Every  now  and  then,  however,  there  will  come  a  case 
in  which  it  is  desirable  that  the  claim  should  be  settled  soon 
after  the  accident.  Money  may  be  wanted  to  tide  over  the 
period  of  disablement  and  to  ensure  the  comforts  necessary 
during  a  time  of  illness,  or  it  may  be  obvious  that  there  is  great 
worry  and  anxiety  as  to  the  prospects  of  recovery  and  the  future 
support  of  the  family.  In  such  circumstances  it  will  not  be  the 
less  beneficial  to  a  man  to  have  his  claim  settled,  but  additional 
care  is  necessary  that  in  doing  so  he  suffer  no  injustice,  I  think 
that  a  claim  for  severe  injury  ought  never  to  be  settled  at  this  time, 
whatever  be  the  want  of  money,  unless  there  is  reasonable  ground 
for  honestly  believing  that  no  fresh  symptoms  indicative  of  a  more 
serious  injury  than  is  then  apparent  are  likely  to  become  developed. 


130  RAILWAY    INJURIES. 

Given  such  conditions,  however,  arrangement  of  claim  is  likely  to 
be  advantageous  to  the  patient,  provided  that  a  fair  basis  for 
settlement  be  made  by  allowing  for  a  certain  period  of  probable 
future  disablement.  And  this  period  has  to  be  defined  by  the 
medical  men  after  an  impartial  consideration  of  all  the  facts  of  the 
case.  To  lay  down  here  in  a  book  any  hard  and  fast  rule  is 
manifestly  impossible,  as  likewise  it  is  well  nigh  impossible  to 
describe  the  indications  for  arrangement  of  claim  as  a  remedial 
agent.  At  the  bedside,  however,  there  is  not  much  difficulty  in 
deciding  whether  arrangement  of  .claim  is  advisable,  and  likely  to 
be  followed  by  good,  or  the  reverse  ;  nor  is  it  I  think  very  difficult 
to  say  beforehand  whether  the  settlement  of  claim  will  be  followed 
by  immediate  recovery,  or  will  only  act  remedially  by  conducing 
to  settlement  of  mind.  It  is,  at  any  rate,  quite  erroneous  to  jump 
to  the  conclusion  that  a  man  is  a  swindler,  simply  because  he 
recovered  soon  after  getting  a  cheque  from  the  railway  company  ; 
and  there  need  not  be  the  smallest  imputation  upon  a  man  in  telling 
him  that  he  had  very  much  better  arrange  his  claim,  and  that  in 
all  probability  if  he  does  so  he  will  soon  be  well.  I  have  many 
times  been  assured  by  compensated  persons  themselves,  that  the 
moment  they  got  the  thing  settled  they  felt  quite  different  beings, 
and,  simply  because  the  matter  was  off  their  minds,  at  once  began 
to  improve.  And  this,  too,  in  cases  where  there  has  been  severe 
and  genuine  disturbance  of  health.      Here  is  a  case  in  point. 

Case  38, — Slight  injury  and  nervous  shod' — Anxiety  as  to 
claim  and  delayed  convalescence. — W.  A.,  a  stout  elderly  man, 
was  in  a  rather  severe  collision.  He  was  able  to  continue  his 
journey  after  the  accident,  but  in  two  or  three  days  he  began 
to  have  pains  in  the  back  and  to  feel  himself  shaken,  weak,  and 
ill.  He  then  returned  home,  a  journey  of  four  hours,  and  went 
to  bed.  There  were  no  signs  of  injury  other  than  those  of  slight 
sprain  of  the  muscles  of  the  back,  with  general  nervousness  and 
loss  of  tone.  He  steadily  improved,  and  in  two  months  it  was 
thought  that  he  was  sufficiently  well  to  arrange  and  settle  his 
claim.  He  then,  however,  began  to  complain  more  ;  and  four 
months  after  the  accident  he  looked  worse  than  hitherto,  appeared 
ill  and  anxious,  expressed  himself  unable  to  leave  the  house,  and 
wholly  unfit  even  to  think  of  resuming  his  business.  This  went 
on  for  several  months,  and  instead  of  any  improvement  taking 
place,  he  began  to  look  more  aged  and  worn,  and  not  having 
been  out  of  doors  for  a  long  time,  lost  appetite  and  weight,  became 
prone  to  cry,  and  altogether  presented  an  aspect  so  unhappy,  that 


"MEDICO-LEGAL    ASPECT    OF    RAILWAY    INJURIES.         I3I 

an  opinion  was  given  that  he  was  permanently  injured  from 
"  concussion  of  the  spine,"  and  would  never  be  fit  to  do  anythinor 
again.  There  were,  however,  no  symptoms  of  serious  illness  or 
disease,  and  settlement  of  his  claim  was  confidently  anticipated 
as  the  one  thing  essential  to  restore  him  to  health.  Nine  months 
passed  without  a  shadow  of  improvement,  and  his  claim  was  at 
length  arranged.  In  a  very  short  time  he  was  perfectly  well, 
looked  in  good  health,  and  "  ten  years  younger  "  than  before  his 
claim  had  been  settled.  Nor  was  this  improvement  transitory. 
He  continued  in  perfect  health,  and  five  years  after  the  accident 
was  following  his  occupation  with  his  usual  vigour  and  in  his 
former  state  of  health. 

A  case,  it  may  be  suggested,  devoid  of  all  colour,  and  wanting 
any  tangible  symptom  at  all,  if  we  exclude  the  pain  in  the  back 
which  in  former  times  was  pretty  sure  to  conjure  up  "  concus- 
sion of  the  spine."  But  it  is  just  these  colourless  cases  which 
are  often  the  most  difficult  of  diagnosis,  especially  to  those  who 
have  never  seen  anything  like  them  before.  "  I  cannot  make  out," 
his  doctor  says,  "  why  this  patient  does  not  get  well.  He  seemed 
to  mend  at  first,  and  I  thought  he  was  going  to  get  over  it  soon, 
but  now  he  appears  to  have  no  energy  at  all.  Medicines  don't 
do  him  any  good.  I  urge  him  to  make  an  effort  to  get  about 
and  try  a  little  business,  but  he  says  he  cannot ;  or  if  he  does, 
that  he  breaks  down  again  almost  before  he  has  begun."  Com- 
plaints like  this  would  not  be  heard  quite  so  often  perhaps,  were 
this  clinical  fact  more  fully  recognised,  that  settlement  of  claim  is 
frequently  the  most  important  agent  to  bring  about  recovery. 

You  need  not  seek  to  inquire  too  closely  into  the  rationale 
of  the  change  which  may  be  thus  induced.  There  is  a  release 
from  the  mental  worry  and  annoyance  inseparable  from  any 
long  dispute,  and  a  feeling  that  now,  the  whole  trouble  being 
over,  a  fresh  start  is  possible,  and  that  persistent  effort  may 
once  more  be  made  to  move  about  and  resume  work.  Doubtless 
also  there  is  some  satisfaction  in  placing  a  good  round  cheque  to 
your  balance  at  the  bank,  which,  in  this  age  of  progress  and 
poverty,  exerts  a  stimulus  which  no  pharmacopoeial  preparation 
can  supply.  The  attitude  of  the  patient's  own  thoughts  is 
wholly  altered.  Before  compensation  was  effected  he  held  out 
a  goal  to  himself,  and  thought,  and  said — "  When  my  claim  is 
settled  I  will  try  and  resume  work  ;  but  I  will  wait  and  see  how 
I  am."  When  his  claim  has  been  arranged  he  arc^ues  thus — 
"  Now  I  must  begin  my  work  again,  and  do  the  best  1  can." 
The  effbrtj  at  all  events,  can   at  length  be  made,  and  with  each 


132  RAILWAY    INJURIES. 

succeeding  hour  of  activity  and  occupation  there  grows  up  a 
healthier  tone,  and  the  role  of  the  invalid  is  laid  aside. 

It  is  not  only  in  cases  like  these,  hovvever,  that  settlement 
and  repose  of  mind  conduce  to  speedy  recovery.  A  like  result 
may  be  seen  elsewhere ;  and  it  is  a  well-known  fact,  that  the 
health  of  prisoners  in  gaol  has  unquestionably  improved  after  they 
have  received  their  sentence,  even  though  the  sentence  may  have 
been  far  more  severe  than  they  had  expected. 

While,  then,  we  cannot  ignore  the  influence  of  this  restora- 
tive agent,  we  must  be  more  careful  than  ever  that  our  knowledge 
of  its  efficacy  be  not  improperly  applied.  An  accurate  history  of 
the  injury,  and  of  the  accident  in  which  it  was  received;  a  care- 
ful observation  of  the  patient's  condition  immediately  after  the 
accident,  and  of  his  progress  in  the  days  and  weeks  which 
followed ;  an  impartial  comparison  of  his  case  with  others  of 
a  like  kind  which  have  been  met  with  before — these  things 
will  guide  to  a  right  estimate  of  the  facts  when  recovery  seems 
to  be  unduly  slow,  and  when  examination  reveals  no  signs 
of  disease  to  account  for  the  delay.  And,  although  it  does  not 
fall  within  his  province  or  business  to  deal  with  the  matter  in 
any  way,  it  is  yet  necessary  for  the  doctor  sometimes  to  know 
what  steps  the  patient  is  taking  to  obtain  compensation,  and  how 
far  this  question  may  presumably  be  engaging  his  mind. 


Danger  of  3.  It  luust  be  remembered,  however,  that,  although  compensa- 
.p?estions.  ^^°^^  ^^^^  ^^^^^  influence  upon  the  recovery  of  patients  about  whose 
bona  fides  there  may  be  no  suspicion,  with  others  it  may  act  as 
an  irresistible  temptation  to  wrong.  Hence  arise  some  of  those 
difticulties  which  surround  the  clinical  inquirer,  and  which  entail 
obvious  duties  and  precautions  on  the  medical  man.  He  must 
endeavour  to  hold  the  balance  as  evenly  as  may  be  between  the  two 
sides  which  are  more  especially  concerned  in  every  medico-legal 
inquiry ;  and  it  behoves  him,  above  all  things,  to  take  care  that 
no  affection  of  coincident  origin,  nor  any  precedent  deformity  or 
disease  shall  be  allowed,  through  ignorance  or  carelessness  on  his 
pai't,  to  form  an  item  in  the  claim  which  the  patient  may  think 
fit  to  make  for  the  injuries  he  has  sustained. 

You  can  never  tell  how  readily  a  patient  may  adopt  a  sugges- 
tion which  has  been  unwittingly  put  into  his  mind,  or  how  soon 
an  unguarded  word  or  opinion  may  give  a  tone  to  the  symptoms 
which  they  would  not  otherwise  possess.  Avoid,  therefore,  as 
far  as  possible  all  leading  questions,  because  the  use  of  them  may 


MEDICO- LEGAL    ASPECT   OF    RAILWAY    INJURIES.         I  33 

suggest  symptoms  whicli  had  no  previous  existence.  In  a  gross  case 
of  fraud  which  fell  under  my  notice,  a  grave  opinion  was  formed 
of  the  symptoms  because  a  leading  question  prompted  an  answer 
which  was  wholly  untrue.  The  man  complained  of  giddiness ; 
and  as  vertigo  was  known  to  be  often  the  result  of  diplopia,  the 
patient  was  hastily  asked  if  he  saw  double.  "  Yes,"  was  the  reply  ; 
and  led  on  by  further  leading  questions,  a  very  serious  train  of 
alleged  symptoms  was  revealed.      Not  one  of  them  was  true. 

The  clever  impostor  who,  some  years  ago,  went  the  round  of 
the  hospitals,  and  simulated  many  nervous  disorders  with  vary- 
ing degrees  of  success,  lacked  in  his  marvellous  exhibition  of 
tetanus  the  usual  rigidity  of  the  abdominal  muscles.  A  remark 
was  made  at  his  bedside,  when  he  was  in  one  of  the  worst  of 
his  seizures,  that  it  was  strange  the  tetanic  spasm,  so  extreme 
elsewhere,  should  not  also  affect  the  muscles  of  the  abdomen. 
The  next  day  they  were  as  hard  as  a  board. 


4.   Not  less  important,  also,  is  it  to  avoid  the  unnecessary  use  The  use 
of  leading  methods  of  exanunation.      I  would  not  in  the  smallest  oHnstru-^ 
degree  detract  from  the  value  of  instruments  of  precision,  but  ments  of 

.  .  ,  .  "^  precision. 

their  use  is  often  cpiite  unnecessary,  the  cases  being  singularly 
few  and  far  between  which  demand  the  whole  armainenta  of  the 
specialist,  who  with  dynamometer,  aesthesiometer,  audiometer, 
lenses,  and  batteiy,  finds  out  some  trifling  departure  from  the 
normal  which  may  be  made  the  unfair  groundwork  of  a  claim. ^  Of 
what  eartlily  use  are  observations  by  the  dynamometer,  for  example, 
unless  you  know  that  the  patient  is  telling  you  the  truth  ?  You 
discover,  forsooth,  that  he  squeezes  with  a  force  of  50  lbs.  with 
his  right  hand  and  of  10  lbs.  with  his  left,  and  you  forthwith 
create  the  scientific  and  incontrovertible  Ijasis  of  a  lie.  A  little 
common  sense  is  often  of  more  use  in  diagnosis  than  all  these 
instruments  put  together. 


5.  Nor  is  electricity,  as  a   method   of  precise   and    scientific  Eiectncn 
examination,  at  all  exempt  from  these  remarks,  unless  it  shall  tions. 
have  been  made  use  of  by  those  who  are  perfectly  conversant 

1  "Were  a  pathologist,"  writes  Dr.  Moxon  (Croonian  Lectures,  Lauat,  vol.  i., 
1881,  p.  568),  "with  a  great  microscope  to  spy  through  all  our  brains  as  we  sit  here 
in  states  of  satisfaction,  he  would  certainly  see  a  great  deal  in  the  way  of  tortuous 
capillary  and  dots  of  yellow  pigment— a  great  deal  that  under  the  microscope  would 
look  very  alarming." 


134  RAILWAY   INJURIES. 

with  it  ill  ull  its  details,  and  with  the  numerous  fallacies  which 
underlie  its  application.  Years  ago,  when  railway  injuries  were 
more  often  the  cause  of  litigation  than  they  are  now,  it  was  by 
no  means  uncommon  for  evidence  to  be  given  in  court  that  the 
"  electric  test,"  as  it  was  called,  had  been  applied,  and  that  the 
patient,  because  he  could  not  feel,  was  of  necessity  suffering  from 
incurable  central  disease.  Scientific  evidence  has  happily  im- 
proved, and  it  is  recognised  now  that  cutaneous  anaesthesia  has 
no  such  deadly  meaning,  and  that  in  order  to  make  proj)er  use  of 
electricity  in  diagnosis  it  is  essential  to  exclude  those  states  of 
the  skin,  which  prevent  the  reaction  of  the  muscles  being  deter- 
mined by  application  of  electricity  to  them  through  the  cutaneous 
surface.  For  when  patients  have  been  long  confined  to  bed,  and 
from  one  cause  or  another,  from  genuine  fear  of  moving,  from  a 
supposed  inability  to  move  or  from  a  resolve  not  to  move,  have 
kept  their  legs  at  rest,  there  is  likely  to  be  considerable  diminu- 
tion or  even  loss  of  cutaneous  sensibihty.  The  "  electric  test " 
is,  of  course,  useless  in  such  circumstances,  and  because  there 
is  no  response  it  is  altogether  erroneous  to  conclude  that  there 
is  grave  organic  disease.  We  may  perchance  have  to  do  with  a 
case  of  hysterical  anaesthesia,  and  w^e  must  look  to  accompanying 
conditions  to  help  in  diagnosis.  The  reflexes  are  present,  there 
is  no  trophic  disturbance  in  any  part  of  the  limbs,  and  above 
all,  if  the  electric  stimulus  be  brought  into  contact  with  them, 
either  directly  by  needles,  or  after  proper  preparation  of  the  skin, 
it  will  be  found  that  the  reaction  of  the  muscles  is  quite  natural. 
Hear  what  Dr.  Buzzard  has  to  say  on  this  point.  After  describ- 
ing a  case  of  hysterical  paralysis,  he  writes — "  In  this  case,  as  I 
have  seen  in  many  belonging  to  the  class  of  hysteria,^  the  epider- 
mis, which  had  arrived  at  extraordinary  thickness,  apparently 
from  disuse  of  the  limbs,  offered  great  resistance  to  the  passage 
of  electric  currents.  In  these  circumstances  a  more  than  usual 
amount  of  care  in  thorough  soaking  and  rubbing  of  the  skin,  as 
well  as  in  selecting  the  motor  point,  is  necessary  in  order  to 
avoid  fallacies."  ^  The  difficulties  involved  in  the  application  of 
electricity  are  well  indicated  by  the  same  author  in  a  passage 
worthy  of  quotation.  "  We  nevei^  see  in  hysteria  the  various 
muscles  of  one  limb  showing  differing  degrees  of  abnormality  in 
their  response  to  faradaism,  from  a  condition  of  total  absence  of 

1  The  very  cases  that  are  so  often  seen  after  railway  collisiims,  functional  disorders 
of  motion  and  sensation,  and  occasionall}'  real  imposture. 

2  Clinical  Lectures  on  Diseases  of  the  Nervous  System,  p.  liS,  Lecture  V.,  "On 
the  Differential  Diagnosis  between  certain  Hysterical  Conditions  and  Myelitis." 


MEDICO-LEGAL   ASPECT    OF    RAILWAY    INJURIES.         I  35 

reaction  in  some,  to  nearly  a  natural  state  in  others.  Moreover, 
in  hysteria,  according  to  my  observation,  applications  of  electrical 
stimulus  (and  especially  of  the  voltaic  current)  on  one  or  two 
occasions  usually  suffice  to  restore  the  natural  excitability  of  the 
muscles  (equally  in  all)  which  has  simply  declined  through  dis- 
use. A  difficulty  can  only  arise  where  the  observer  has  but  one 
opportunity  of  testing  the  electrical  condition,  and  it  is  then 
quite  possible  to  occur.  It  must  be  remembered  that,  as  a  dis- 
tinct lowering  of  faradaic  excitability  almost  invariably  signifies 
organic  change  in  a  nerve-trunk  or  centre,  a  diagnosis  of  hysteria 
can  never  safely  be  arrived  at  whilst  that  condition  persists. 
On  the  other  hand,  I  need  scarcely  remind  you  that  the  preserva- 
tion of  a  completely  normal  faradaic  excitability  in  the  muscles 
of  a  limb  does  not  show  that  that  limb  is  not  paralysed.  .  .  . 
In  cases  of  paralysis,  it  is  only  when  the  integrity  of  the  grey 
matter  of  the  anterior  horn  is  disturbed,  or  when  there  is  some 
lesion  of  the  anterior  root  or  trunk  of  the  nerve,  that  you  find 
decided  loss  of  electric  excitability.  You  frequently  meet  with 
complete  paraplegia  and  yet  all  the  muscles  will  respond  normally 
to  electric  currents."^ 

In  the  use  of  electricity  for  diagnostic  purposes,  therefore, 
we  must  not  be  content  with  the  negative  evidence  merely  of 
cutaneous  insensibility,  or  absence  of  response  in  the  muscles : 
we  must  look  for  some  such  indication  as  is  given  by  the  reaction 
of  degeneration,  or  by  the  different  reactions  of  various  muscles 
in  the  same  region.  If  these  and  similar  points  are  borne  in 
mind  there  will  be  little  likelihood  of  the  electric  test  being 
vaunted  as  an  infallible  witness  in  a  court  of  law,  and  the  real 
position  of  electricity  as  a  means  of  diagnosis  will  be  less  liable 
to  be  shaken  by  conflict  of  testimony. 


6.   Conflict  of  testimony,  in  other  woi*ds  differences  of  opinion,  Medical 

j_     •  •.     ^  ^  •  •  J'    '     •  T  1  evidence 

must  inevitably  arise  m  many  cases  oi  injury  or  disease,  and  j,^  ^^^^^.g 
the  maladies  considered  in  this  book  are  not  exempt  from  it.  "^  '''^"• 
It  might  be  well,  perhaps,  when  litigation  has  been  resorted  to 
for  the  settlement  of  the  pecuniary  compensation,  if  medical 
men  were  to  be  freed  from  the  necessity  of  giving  evidence  on 
medical  matters  in  open  court.  I  do  not  intend,  however,  to 
say  what  are  my  views  upon  the  subject  in  this  place,  nor  how 
in  my  judgment  the  practice  of  the  courts  might  be  improved. 
Suffice  it  that  testimony  has  still  to  be  given  in  court,  and  that 

^  Op.  cit.,  p.  ICO. 


136  RAILWAY    IXJUltlES. 

ill  giving  it  the  medical  witness  ought  never  to  forget  that  the 
reason  for  his  evidence  is  to  enable  the  court  to  arrive  at  a  just 
and  impartial  conclusion.  If  he  is  himself  a  partisan,  it  is  ob- 
vious that  his  testimony  is  of  small  value  for  the  purpose  named  ; 
and  of  one  thing  he  may  be  certain,  that,  if  a  partisan,  he  is 
tolerably  sure  to  reveal  his  bias  almost  as  soon  as  he  opens  his 
mouth,  and  that  his  testimony  will  be  estimated  accordingly. 
Judge  and  jury  will  alike  put  it  aside.  "  Expert  testimony,"  ^  it 
has  been  well  said,  "  should  be  the  colourless  light  of  science 
brought  to  bear  upon  any  case  when  it  is  summoned.  It  should 
be  impartial,  unprejudiced.  There  should  l^e  no  half  truths 
uttered,  and  suppression  of  the  whole  truth  is  in  the  nature  of 
false  testimony."  It  is  true  that  our  present  methods  render 
the  position  of  the  doctor  very  often  difficult,  for  the  warfare  of 
counsel  and  the  arts  of  cross-examination  tend  to  throw  into 
strong  and  undue  relief  the  slightest  differences  of  opinion,  and 
lead  too  often  to  the  witness  saying  more  or  less  than  he  intended 
to  say.  Patience,  impartiality,  good  temper,  a  sense  of  justice,  and 
a  single  purpose  to  give  utterance  to  the  truth — these,  and  not 
less  than  these,  a  sound  knowledge  of  the  matter  on  whicii  evidence 
is  being  given — will  together  be  his  best  protection  in  the  witness- 
box,  and  will  make  the  taunt  that  doctors  differ  absolutely  harm- 
less to  him.  This  is  what  Chief-Justice  Clinton  said  on  the 
evidence  of  medical  witnesses  in  courts  of  law :  ^ — "  As  to  the 
delivery  of  testimony  by  you  as  experts,  I  have  very  little  to  say 
that  might  not  just  as  properly  be  said  to  a  witness  who  is  called 
to  testify  only  as  to  the  facts  of  the  case.  The  difference  rests 
in  this :  the  expert,  as  such,  is  asked  only  for  his  opinion  upon 
the  facts.  He  may  be  asked  his  opinion  upon  a  hypothetical 
state  of  facts,  and  required  to  give  reasons  for  the  opinion  he 
expresses.  The  cross-examiner  is  allowed  great  latitude,  and  I 
am  sorry  to  say  not  unfrequently  abuses  it.  But  if  the  witness 
will  only  remember  the  worth  and  dignity  of  his  profession,  and 
that  he  is  there  simply  to  speak  truth,  as  a  servitor  of  justice, 
no  arts  or  sneers  of  counsel  can  disturb  him.  Calm  and  self- 
possessed,  he  will  answer  every  question,  direct  or  cross,  fully 
and  in  the  plainest  and  most  lucid  language  in  which  the  mean- 
ing of  the  answ^er  can  be  conveyed  to  the  jury.  To  such  an 
answer  he  will  add  nothing,  iniless  it  be  a  necessary  explanation. 
He  will  not  air  his  learning  before  the  court,  nor  have  any  the 

^  North  Americcn  Review,   1884,  p.  609.  "Expert  testimony."  by   W.  AV.  Gonding, 
quoted  from  Dr.  Wilbur  of  Syracuse,  N.  Y. 

-  Buffalo  Medical  and  Surgiccd  Journal,  Jan.  i,  iSSo. 


MEDICO-LEGAL    ASPECT    OF    RAILWAY    INJURIES.  I  3/ 

least  contention  with  counsel.  The  court  will,  if  need  be,  pro- 
tect him  from  the  abuse  of  lawyers.  Such  a  witness  will  return 
from  the  stand  as  calmly  as  he  went  upon  it,  approved  by 
his  own  conscience,  and  respected  by  the  court,  tlie  jury,  and 
tlie  bar." 


1?>S  RAILWAY    INJURIES. 


BIBLIOGRAPHY. 

1.  Allchix.     "  Functional  diseases."     Westminster  IIusp.  Re2>fs.,  iS86. 

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3.  AvERBECK.     "  Die  akute  Neurasthenie  die  pliJtzliche  Erschopfung 

der  nervosen  Energie."     Deutsche  Med.  Ztg.     Berlin,  1886. 

4.  Benedict.       *'  Ueber     Spiitsymptome     traumatischer    Neurosen." 

Berlin.  Idin.  Wocheiisdirift,  1888. 

5.  Berbez.      "  Hysterie  et  traumatisme."     Paris,  1887. 

6.  Berbez.     "  L'Hystero-traumatisme."     Gaz.  des  H6].\,  1887. 

7.  Bernhardt.       "  Beitrag    zur    Frage    von    der    Beurtheilung    der 

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1888. 

8.  Bramwell.      "  Diseases  of  the  spinal  cord."     Edinburgh,  1884. 

9.  Briquet.     "Traite  clinique  et  therapeutique  de  I'Hysterie."    Paris, 

1859. 

10.  Bristowe.      "  Diseases  of  the  nervous  system."      1889. 

11.  Brodie.      "Lectures    illustrative    of    certain    local    nervous  affec- 

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12.  Brodie.     "  Psychological  inquiries."      1854. 

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14.  BuRCKHARDT.     "  Contribution  a  1'  dtude  de  I'hysterie  traumatique." 

Rev.  med.  de  la  Suisse  Romande,  1886.  y 

15.  Buzzard.     "  Shock  to  the  nervous  system."     Lancet,  1869.  w 

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the  nervous  system."     Brain,  vol.  xiii. 

18.  Casaubon.      "  L'Hyst^rie  chez  les  jeunes  gardens."     These  de  Paris, 

1881. 

1 9.  Charcot.     "  Diseases  of  the  nervous  system."     Vol.  iii.,  Neiv  St/den.  ^ 

Soc,  1889. 

20.  Charcot.      "  Deux  nouveaux  cas  de  paralysie  hysturo-traumatique 

chez  I'homme.''     Procj.  med.,  1887. 

21.  Charcot.      "  Les  accidents   de  chemin    de    fer."     Gaz.    des  Hoj)., 

1888. 

22.  Collier.      "On  traumatic   hysteria  in  the  male."     Med.    Chrou., 

1888. 


BIBLIOGRAPHY.  1 39 

23.  Dana.      "  Concussion  of  the  spine,  and  its  relation  to  neurasthenia 

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24.  Dana.      "The  Aero-neuroses."     N.  Y.  Med.  Rec,  1885. 

25.  Debove.      "Note    sur    I'hysterie    traumatique    et    sur    sa    gravitii 

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27.  Dreschfeld.      "On    hysteria    in    the    male    coming   on    after  an 

injury."     Med.  Chron.,  vol.  v. 

28.  Dreschfeld.     "On  some  rarer  forms  of  hysteria  in  man."     Ibid., 

vol.  xiii. 

29.  DuTiL.      "  Hysterie  et  Neurasthenic  associees."     Gaz.  med.  de  Paria, 

1889. 

30.  Erichsen.      "  On    railway    and   other    injuries    of    the    nervous  * 

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31.  Erichsen.      "  Concussion  of  the  spine."     2nd  edit.,  1882. 

32.  Fere.      "A  contribution   to    the  pathology  of  dreams."      Brain, 

vol.  ix., 

33.  Fere.      "  On  paralysis  by  exhaustion."     Ihid.,  vol.  xi. 

34.  Fere.      "  Nocturnal  paralysis."     Ibid.,  vol.  xii. 

35.  Fletcher.      "  Railways  in  their  medical  aspects."     London,  1867.   *' 

36.  Gavin.      '•  Feigned  and  factitious  diseases."     London,  1843. 

37.  Gee.      "  Irritable  spine  and  spinal  myalgia  in  particular."     Pradi- ^ 

tio7ier,  1884. 

38.  Gowers.     "  Medical  ophthalmoscopy."     3rd  edit.     London,  1890. 

39.  Griffin,  W.  and  D.      "On  functional  affections  of  the  spinal  cord  ^ 

and  ganglionic  system  of  nerves."     London,  1834. 

40.  Groeningen.      "Ueber  den  Shock."     Wiesbaden,  1885. 

41.  GuiNON.      "  L'Hysterie  dans  ses  rapports  avec  la  chirurgie."     Rev. 

de  Chir.,  1888. 

42.  GuiNON.      "Les  agents  provocateurs  de  I'Hysterie."     Paris,  1889. 

43.  Heidenhain.     "Animal  magnetism."     London,  1880. 

44.  Hodges.      "  So-called  concussion  of  the  spinal  cord."     Boston  Med.  ^ 

and  Surg.  Jour.,  1881. 

45.  Hutchinson.     "  The  symptom -significance  of  different  states  of  the 

pupil."     Brain,  vol.  i. 

46.  Inman.     "On  Myalgia,  its  nature,  causes,  and  treatment."      2nd 

edit.,  i860. 

47.  Jones  Handfield.     "  Clinical  observations  on  functional  nervous 

disorders."     London,  1864. 

48.  Jordan  FuRNEAux.      "  Surgical  Enquiries."     2nd  edit.,  1882. 

49.  KiRMissoN.      "  Nouveau  cas  d'hystero-traumatisme."     Bid/,  de  la 

Soc.  de  Chir.,  1888. 

50.  Knapp.     "  Nervous  affections  following  injury."     Bout  on  Med.  and 

Sunj.  Jour.,  1888. 

51.  Kuhner.      "Zur  gerichtsiirtzlichen  Wurdigung  der  in  Folge  hef- 

tiger  Korpererschlitterungen,    insbesondere    nach   Eisenbahnun- 


I40  RAILWAY    INJURIES. 

fallen  auftretenden   nervosen   Storungen."      Friedreichi^   Bl.  fur 
gerichtl.  Med,  i8go. 

52.  Maas.     "Ueber  die  Verletzungen  durch  den  Eisenbahnunfall  bei 

Ilugstetten,  &c.,  &c."     Arch.  f.  Id.  Chir.,  vol.  xxxi.,  1884-85. 

53.  Marcet.      "  History  of  a  singular  nervous  or  paralytic  affection." 

Trans.  Med.  Cliir.  Soc,  vol.  ii.,  1810. 

54.  Mathieu.      "  Neurasthenie  et  hysterie   combinees."      Prorj.   med., 

1888. 

55.  Mendel.     '' Die  Hypochondrie  beim  weibliclien  Gescblecht."     Deut. 

med.  Wochenschrift,  1889. 

56.  Mercier.      "  Sanity  and  insanity."     London,  1890. 

57.  Meynert.      "  Ueber  functionelle  Nervenkrankheiten."      Wien.  med. 

Presse,  1883. 

58.  Mitchell  Weir.      "  Diseases  of  the  Nervous  System,  especially  in 

women."     London,  1885. 

59.  MoELL      "  Ueber  psycbisclie  Storungen  nacb  Eisenbahnunfiillen." 

Berlin,  kliii.   Wochenschrift,  1881. 

60.  Moll.   "Hypnotism."     London,  1890. 

61.  Money.      "The  production  of  ankle-clonos  under  various  circum- 

stances."     Brit.  Med.  Jour.,  vol.  ii.,  1887.  ; 

62.  MoRicouRT.     "  Hysterie  chez  I'homme."     Gaz.  des  Hop.,  1887. 

63.  Morris.     "On    shock    caused    by    railway    accidents."       London,  1^ 

1S67. 

64.  Obersteiner.      "  Erschiitterung  des  Eiickenmarks."     1889. 

65.  Oppenheim.      "Die  traumatischen  Neuro.sen."     Berlin,  1889. 

66.  Oppenheim.      "  Wie   sind  die    Erkrankungen    des    Nervensystems 

aufzufassen,  welche  sich  nach  Erschiitterung  des  Riickenmarks, 
insbesondere  Eisenbahnunfallen,  entwickeln  ? "  Berlin,  iclin. 
Wochenschrift,  1888. 

67.  Oseretzkowsky.     "  Quelques  cas  d'hysterie  dans  les  troupes  russes." 

Arch,  de  Neurol.,  1886. 

68.  Page.     "  Injuries  of  the  spine  and  spinal  cord,  itc."    2nd  edit.,  1885 

69.  Page.   "  On  the  abuse  of  Bromide  of  Potassium  in  the  treatment 

of  Traumatic  Neurasthenia."    Med.  Times  and  Gaz.,  vol.  i.,  1885. 

70.  Paget.    "  Clinical  lectures  and  essays."     2nd.  edit.,  1879. 

71.  Parinaud.      "  De  la  polyopie   monoculaire,  dans  I'hysterie  et  les 

affections  du  systeme  nerveux."     Annates  d'  Oculistique,  1878. 

72.  Pitres.     "  Des  ansesthesies  hysteriques."     Bordeaux,  1887. 

73.  Pitres.   "  Des  tremblements  hysteriques."     Pror/.  med.,  September 

1889. 

74.  Putnam.     "  Recent  investigations  into  the  pathology  of  so-called*^ 

concussion  of  the  spine."     Boston  Med.  and  Surg.  Jour.,  1883. 

75.  Putnam.      "  The  medico-legal  significance  of  hemiansesthesia  after 

concussion  accidents."     Amer.  Jour,  of  Neurolorpj,  1884. 

76.  Putnam- Jacobi.     "  Some  considerations  on  hysteria."     Med.  Rec, 

1S86. 


BIBLIOGRAPHY.  I4I 

77.  QuiNQUETON.    "  De  riiysterie  chez  rhomme."    IVu'se  de  Paris.  18S6. 

78.  Reynolds  Russell.     "  Paralysis  and  other  disorders  of  motion 

and  sensation  dependent  on  idea."     Brit.   Med.   Jour.,  vol.   ii., 
1869. 

79.  Richer.      "  Etudes  cliniques   sur  I'llystero-epilepsie    ou   grande 

hysterie."     Paris,  1881. 

80.  RiEGLER.     "  Ueber  die  Folgen  der  Verletzungen  auf  Eisenbahnen, 

&c."     Berlin,  1879. 

81.  Ross.      '•  Diseases  of  the  nervous  system."     London,  1883. 

82.  Ross.      "  On   the   segmental    distribution    of  sensory  disorders." 

Brail/,  vol.  x. 

83.  Savill.      "  Two  cases  of  neuropathic  (Hysterical)  spinal  disease." 

St.  Thomas'  Hosp.  Mepts.,  vol.  xviii. 

84.  Savory.     Arts.   "  Hysteria  "  and   "  Collapse,"  Holmes'  System  of 

Surgery,  3rd  edit.,  vol.  i.,  1883. 

85.  Shaw.     Art.   "  Diseases  of  the  spine,"  Holmes'  System,  2nd  edit., 

vol.  iv. 

86.  Skey'.     "  Hysteria,  ikc."      London,  1867. 

87.  Strumpell.     "  Ueber  die  traumatischen  Neurosen."    Berlin  Klin., 

1888,  Heft  3. 

88.  SuLLY'.      "Illusions."     2nd  edit.,  London,  1881. 

89.  Terrier.     "Troubles  hysteriques  d'origine  traumatique."     Bull. 

de  la  Soc.  de  Chir.,  vol,  xiv. 

90.  Thorburn.      "  A  contribution  to  the  surgery  of  the  spinal  cord."  *^ 

London,  1889. 

91.  TuKE  Hack.     "Influence  of  the  mind  upon  the  body."     3rd  edit., 

London,  18S9. 

92.  Vibert.      "Etude  m^dico-legale  sur  les  blessures  produites  par  les 

accidents  de  chemin  de  fer."     Paris,  1888. 

93.  Walton.      "  Possible  cerebral  origin  of  symptoms  usually  classed  *^ 

as  'railway  spine.'"     Boston  Med.  a7id  Surg.  Jour.,  1883. 

94.  Walton.      "Spinal  irritation;  probable  cerebral  origin  of,  &c." 

Ilnd.,  1883. 

95.  Walton.      "  Hysterical    hemiansesthesia,   ttc,    brought  on   by    a 

fall."     Ibid.,  1884. 

96.  Walton.     "  Deafness     in     hysterical    hemiansesthesia."     Brain, 

vol.  V. 

97.  Westphal.      "  Einige  Falle  von  Erkrankung  des  Nervensj-stems 

nach  Verletzung  auf  Eisenbahnen."     Charite-Annalen,  1878. 

98.  WiLKS.      "Diseases  of  the  nervous  system."     2nd  edit.,  London, 

1887. 

99.  WiLKS.      "  Hysteria  and  arrest  of  cerebral  action."     Guy's  Hosp. 

Bepfs.,  vol.  xxii. 
100.   Wolff.     "  Ueber  Railway- spine."     Deutsche  jned.  Zl(/.,  iSSS. 


INDEX. 


Abortion,  rarity  of,  after  railway  accident,  45. 
Accidents,  railway,  alarming  nature  of,  28. 

importance  of  learning  kind  of,  121. 
Accommodation,  weakened,  in  neurasthenia,  42. 
Acute  hysteria,  64. 
Alcohol,  in  neurasthenia,  102. 

Allbutt,  Dr.  Clifford,  optic  changes  in  spinal  diseases,  43 
Ammonium,  bromide  of,  102. 
Anaemia,  transient  local,  in  neurasthenia,  54. 
Ancesthesia,  from  disuse  of  limbs,  134. 
Analgesia,  hysterical,  in  children,  in. 
Anxiety,  as  to  claim,  113. 

Oppenheim  upon,  95. 
Aphonia,  hysterical,  79. 
Asthenopia,  in  neurasthenia,  42. 
Asymmetry,  bodily,  in  malingering,  log. 
Atropine,  use  of,  in  malingering,  107. 
Attention,  fixed,  on  bodily  sensations,  54. 
Auto-suggestion,  69. 

Back,  frequency  of  injury  to  the,  i. 

hypergesthesia  of  tlie,  10. 

pain,  stiffness,  and  tenderness  of  the,  5. 
Bladder,  atony  of,  from  shock,  7,  45. 

the  "  nervous,'"'  8. 
Bones,  fractures  of,  influence  on  neurasthenia.  57. 
Bowel,  hsemorrliage  from,  in  malingering,  107. 
Brain,  fatigue  of,  in  neurasthenia,  40. 
Briquet,  on  predisposition  to  hysteria,  63. 
Bristowe,  Dr.,  on  "  functional  vomiting,"  85. 
Bromide  of  potassium,  abuse  of,  loi. 
Bursce,  distended,  in  malingering,  109. 
Buzzard,  Dr.,  on  syphilitic  paraplegia,  20. 

on  the  use  of  electricity  in  diagnosis,  1 34. 

Catalepsy,  cases  of  hypnotic,  89,  92. 

Heidenhain  on,  92. 
Catamenia,  derangements  of,  in  neurasthenia,  44. 


INDEX.  143 


Charcot,  M.,  on  accidental  discovery  of  heraiansesthesia,  76. 

on  railway  collisions,  68. 

on  suggestion,  67. 
Chronic  invalidism;  54. 
Circulation,  disturbances  of,  from  shock,  25,  38. 

in  functional  nervous  disorders,  54. 
Clinton,  Chief- Justice,  on  expert  evidence,  136. 
Cold,  sensations  of,  after  shock,  39. 
Collapse,  25. 

Canfifensation,  23,  54,  112,  127. 
Conflict  of  testimony,  135. 
Constipation  in  lumbago,  8. 

Gonsiiht^tons  predisposing  to  the  functional  neuroses,  56,  63. 
Convalescence  and  compensation,  54,  129. 
Convulsions,  voluntarily  induced,  73. 
Cross-examination,  136. 
Cystitis,  after  spinal  sprain,  7. 
Cysts,  sebaceous,  in  malingering,  109. 

Death  from  uncomplicated  shock,  47. 
Deception,  self-,  in  hysteria,  in. 
Delusions,  92,  96. 

Diarrhoea,  from  vaso-motor  paresis,  41. 
Digestion,  in  neurasthenia,  45,  102. 
Diplopia,  in  malingering,  133. 
Dynamometer,  use  and  abuse  of  the,  133. 

Electricity,  in  hysteria,  134. 
^''  Electric  test,"  the,  134. 
Emotions,  lost  control  over,  50. 
Eserine,  use  of,  107. 
Evidence,  expert,  135. 
Exaggeration,  54,  114,  126. 
Expectance/  and  suggestion,  67. 
Exj)ert  testimony,  136. 
Eyesight,  defects  of,  in  neurasthenia,  42. 
in  malingering,  107. 

Facial  nerve,  peripheral  paralysis  of  the,  in. 
Family  history,  predisposing  to  nervous  disorder,  63. 
Fatigue  of  brain,  in  neurasthenia,  40. 
Fear  of  moving,  8. 
Fear  of  paralysis,  69. 
Flushings,  in  neurasthenia,  54. 
Fractures  and  general  nervous  sliock,  57. 
Fright,  death  from  shock  alter,  47. 

deferred  syncope  from,  29. 

the  cause  of  shock  in  railway  collisions,  27,  29,  ^2^  51. 
Frigld-neiiroses,  the,  61. 

different  types  of  the,  95. 
Functional  nervous  disorders,  62. 

absence  of  coarse  organic  disease  in  the,  62. 


144  INDEX. 

Fundioyial  nervous  disorders,  predisposition  to  suffer  from,  63. 
Fundus  oculi,  changes  in,  in  cord  lesions,  43. 

(iavin,  on  tympanitis,  107. 

GenitoAirlnarij  derangements,  45. 

Giddiness,  from  circulatory  disturbance-',  40. 

Globus  hystericus,  40. 

Gout  and  sprains  of  the  back,  100, 

Gowers,  Dr.,  on  optic-disc  changes  in  cord  diseases,  44. 

Griffin,  the  brothers,  on  hypersesthesia  of  the  back,  10. 

Gummata,  in  imposture,  109. 

Hmmorrhage,  from  the  bowel,  in  malingering,  107. 
Head,  oppression  and  pain  of,  in  neurasthenia,  39. 
Heart,  palpitation  of  the,  38. 

paresis  of  the,  in  shock,  25. 
Heat,  sensations  of,  after  shock,  39. 
Heidenhain,  Dr.,  on  catalepsy,  92. 

on  hypnotism,  73.  ' 

Hemiancesthesia,  85. 

Dr.  Putnam  on,  125. 
Hernia,  in  imposture,  109. 
Hutchinson,  Mr.,  on  the  use  of  atropine,  loS. 
Hydrocele,  in  imposture,  109. 
Hypercemia,  transient  local,  54. 
Hypercesthesia  of  the  back,  10. 
Hypermetropia,  in  neurasthenia,  42. 
Hypnotic  cataleps//,  89. 
Hypnotism,  65. 

objections  to,  y^. 

state  of  the  sensoriuni  in,  72. 

suggestion  in,  67. 

voluntarily  induced,  "j^. 
Hypochondriasis,  95. 
Hysteria,  acute,  64. 

abeyance  of  will  in,  52. 

anaesthesia  of  the  skin  in,  125,  134. 

exaggeration  in,  54,  114,  126. 

with  spinal  injuries,  22. 

in  men,  50,  81. 

and  neurasthenia,  36. 

"  traumatic,"  6 1 . 

vomiting  in,  83. 

Insanity,  predisposing  to  neuromimeses,  89. 
Instruments  of  precision,  133. 

Joints,  sprains  of,  10. 

stiffness  of,  in  malingering,  104,  119. 

sprains  of  spinal,  treatment  of,  98. 
Jordan,  Mr.  Furneaux,  on  deferred  shock,  29. 

on  hysteria  in  men,  50. 

on  shock  from  fright,  28. 


INDEX.  145 

Knee-joint,  simulated  disease  of,  119. 

Lactation,  from  vaso-motor  paresis,  41. 
Leading  questions,  (^y ,  132. 
Ligaments,  sprains  of  spinal,  3,  6,  14. 
Limbs,  position  of,  in  malingering,  105. 
Litigation,  evil  effects  of,  54. 
"  Litigation  symptoms,"  4,  54. 
Lumbago,  traumatic,  2,  69,  99. 
pseudo-palsy  from,  6. 

Malingering,  bodily  asymmetry  in,  108,  109. 

hfemorrhage  in,  107. 

precedent  disease  in,  108. 

starvation  in,  114,  115. 

stiffness  of  joints  in,  105. 

sweating  in,  121. 

the  motive  for,  112. 

tympanitis  in,  106. 

use  of  atropine  in,  107. 

vomiting  in,  120. 
Massage,  99. 

Medico-legal  remarks,  127. 
Memory,  loss  of,  44. 
Meningitis,  spinal,  syphilis  and,  20. 

rarity  of,  after  railway  injury,  21. 

subacute,  20. 

"traumatic,"  18,  20. 
Menorrhagia,  41,  44. 
Micturition,  difficulty  of,  in  lumbago,  7. 
Mitchell,  Weir,  the,  treatment,  103. 
Movement,  fear  of,  8. 

treatment  by,  99. 
Moxon,  on  morbid  cerebral  changes,  133, 
Muscce  volitantes,  42. 
Muscles,  spinal,  sprains  of,  3. 
Myalgia,  99. 
Mydriasis,  107. 
Myelitis,  fatal  case  of,  18. 

Nerves,  spinal,  injury  to  trunks  of,  4,  16. 

of  pelvis  and  thigh,  injury  to,  15,  17. 
Nervousness,  40. 
Nervous  shock,  general  (see  also  Shock),  25. 

after  fractures,  57, 

with  spinal  sprains,  22. 

and  the  neuromimeses,  63. 

spurious,  114,  119. 
Neurasthenia,  and  hysteria,  36,  49. 

bromide  of  potassium  in,  10 1. 

from  fright,  35. 
Neuromimeses,  the,  61. 


146  INDEX. 

Neuromimeses,  the,  changes  underlying,  62. 

the  chronic,  65. 

induced  by  nervous  shock,  63. 

iu  malingering,  123. 
Numbness,  13. 
Nutrition,  derangements  of,  102. 

Occipital  headache,  39. 

Occupation,  -want  of,  55,  118. 

Oppenheim,  on  psychical  commotion,  71,  95. 

Optic  disc,  state  of,  in  cord  diseases,  43. 

Orchitis,  in  myelitis,  18. 

Organic  sensations,  in  neurasthenia,  52. 

Sully  upon  the,  53. 
Ovarian  derangements  from  shock,  44. 

Paget,  Sir  James,  on  weakness  of  the  will,  77. 
Pachymeningitis,  syphilis  and,  20. 
Pain,  in  traumatic  lumbago,  3,  5,  7. 

nature  of,  in  spinal  sprains,  9. 

spinal,  with  neurasthenia,  4,  5. 
Palpitation,  38. 
Paralysis,  feignings  of,  6. 

peripheral  facial,  in. 
Paraplegia,  cases  of  "functional,"  75,  7^. 

cerebral  origin  of  hysterical,  65. 
Paresis  of  the  circulation,  25. 
Peripheral  sensations  after  spinal  injury,  12. 
Photophobia,  42. 
^^  Pins  and  needles,"  13. 
Polyuria,  41. 
Poroplastic  jackets,  9,  100. 
Potassium,  bromide,  abuse  of,  loi. 
Precedent,  diseases  in  malingering,  108. 
Pregnancy,  45. 

Prisoners,  influence  of  sentences  on,  132. 
Prognosis,  in  neurasthenia,  59. 

after  spinal  injuries,  17,  100. 
Pseudo-palsy,  from  traumatic  lumbago,  7. 
Pulse,  the,  in  neurasthenia,  26,  38. 
Pupil,  size  of  the,  42. 

in  malingering,  107. 
Putnam,  Dr.,  on  hemiantesthesia,  125. 

Questions,  use  of  leading,  97,  132. 

Railway  collisions,  effect  on  the  spine,  2. 

Charcot  upon,  68. 

fright,  the  cause  of  shock  in,  27. 

malingering  after,  112. 
Reaction  after  shock,  27. 


INDEX.  147 


Recovery,  after  general  nervous  shock,  59. 

after  railway  injuries,  128. 

delay  in,  causes  of,  50,  54. 
Refraction,  errors  in,  42. 
Retention  of  urine  from  shock,  7,  45. 
Rest,  the  use  of,  14,  100,  103. 
Rheumatism  and  spinal  sprains,  100. 
Riegler,  Dr.,  on  railway  injuries,  i. 
Ross,  Dr.,  on  syphilis  of  the  nervous  system,  21. 

Sacral  plexus,  injury  to,  15,  17. 

Secretion,  disorders  of,  41. 

Sensations,  the  organic,  52,  53. 

Sensorium,  the,  in  hysteria,  65. 

Sexual  exhaustion,  57. 

Shaw,  on  the  small  spinal  joints,  6. 

Shock  (see  also  Nervous  Shock),  nature  of,  25. 

asthenopia  after,  42. 

catamenial  derangements  after,  44. 

death  from  uncomplicated,  47. 

deferred,  28. 

disturbances  of  circulation  after,  25,  38. 

effects  of  railway,  on  pregnane}-,  45. 

evil  effects  of  litigation  after,  54. 

and  fractures,  57. 

from  fright,  27,  29,  ^2),  S^- 

Furneaux  Jordan  on,  28,  29. 

headache  after,  39, 

hysterical  seizures  after,  39. 

and  spinal  sprains,  4,  23. 

loss  of  memory  after,  44. 

organic  sensations  after,  52. 

photophobia  after,  42. 

predisposition  to  neuromimeses,  63.' . 

retention  of  urine  after,  7,  45. 

secretory  disorders  after,  41. 

sleeplessness  after,  37. 

spinal  injuries,  and,  4,  22. 

"  spurious  nervous,"  114,  118. 

sweating  after,  41. 
Sleeplessness,  37. 

treatment  of,  102. 
Sodium,  bromide  of,  loi. 
Spasm,  functional,  of  arm,  80. 
Spinal  irritation,  10. 
Spine,  severe  bend  of,  13. 

fear  of  moving  after  sprain  of,  8. 

frequency  of  injury  to,  i. 

gait,  the,  after  sprains  of,  7. 

hyperesthesia  of,  10. 

pain  in  severe  sprains  of,  3,  5,  7,  9, 


148  INDEX. 

Spine,  prognosis  after  injuries  of,  17,  100. 

pseudo-palsy,  from  S23rains  of,  7. 

sprain  of,  and  neurasthenia  combined,  23. 

stiffness  of,  5,  99. 

tenderness  of,  5. 

treatment  of  sjirains  of,  14,  99.  103. 
Starvirtfj,  in  imposture,  114,  115. 
Subjective  symptoms,  in  malingering,  1 1 9. 
Sziggestion,  auto-,  69. 

in  hypnosis,  66,  jj,  81,  83. 

Charcot,  on  "traumatic,"  67. 
Sully,  Air.,  on  the  organic  sensations,  53. 
Suspense  of  mind,  129. 
Sweating,  in  neurasthenia,  41. 

purposely  induced,  121. 
Sxjphilis  and  meningitis,  20. 

Dr.  Buzzard,  case  of  paraplegia,  20. 
System-diseases  of  the  spinal  cord,  22. 

Taclie  cerebrale,  in  neurasthenia,  39. 

Temperament,  the  nervous,  3,  51,  63. 

Tenderness  of  the  spine,  5,  6. 

"Test,  the  electric,"  134. 

Tetanus,  simulated,  133. 

Thorburn,  Mr.,  on  the  fear  of  paralysis,  69. 

on  hypnotism,  70. 

on  optic  changes  after  spinal  injuries,  43. 

on  the  traumatic  neuroses,  36. 
Traumatic  hysteria,  61. 
Traumatic  lumbago,  2. 
Treatment,  98. 

Tumours,  fatty,  in  malingering,  109. 
Tympanitis,  in  malingering,  106. 

Urine,  retention  of,  from  shock,  7,  45. 
Uterus,  the  pregnant,  in  railway  accidents,  45. 

Varicocele,  in  imposture,  109. 
Vaso-motor  derangements,  41. 
Vision,  defects  of,  in  neurasthenia,  42. 
Vomiting,  hysterical,  and  in  malingering,  83,   120. 
Bristowe,  Dr.,  on,  85. 

Wilks,  Dr.,  on  hysteria,  88. 
IFill,  the,  in  hysteria,  59.  66,  88. 

Paget,  on  weakness  of  the,  yj. 
Witness,  the  medical,  135. 


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